**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 409 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia, pneumonia, [NAME]-Pick Disease Type C, fracture of neck of left femur, mild cognitive impairment, and acute kidney failure. Resident 409's medical record was reviewed from 10/7/24 through 10/21/24. A quarterly MDS assessment dated [DATE], indicated resident 409 had a BIMS score of 00 which suggested severe cognitive impairment. Per facility documentation, an incident of abuse between resident 409 and resident 209 occurred on 7/31/23. The following was documented: A Nursing Progress note, dated 8/1/23 at 2:02 AM, indicated, Male CNA reported that he went to check resident [409] bc [because] he was told he didn't have a brief. Upon entering the room he noticed that his roommate, resident [209], was looking at resident [409] and was up against resident [409]'s bed. Staff rediretd [sic] resident [209] back to his side of the room, closed the curtain and proceeded to assist resident [409] with his brief. Staff notice that there was a whitish discharge noted arouind [sic] penile area. After assisting resident [sic] [409] with brief he left the room and left the door open. Staff wentback [sic] a few minutes later to check on them and saw that the bedroom door was closed. He opened the door and saw that resident [209] was by resident [409]'s bed, touching him inappropriately with his hand on resident [409]'s genitals. He intervened and redirected resident [209] away from resident [409]. CNA reported incident to nurse and resident [209] was removed from room and placed into another unoccupied room in a different area of the unit. Incident reported to administrator, DON, ADON [Assistant Director of Nursing] and Provider. Review of the Form 358: Reported Incidents, dated 8/1/23 at 12:20 AM, for resident 409 documented, .[Resident 209] was witnessed by CNA [staff name redacted], at approximately 2215 [10:15 PM] near [resident 409's] bed inappropriately touching his genital area. CNA was reported to separate residents immediately and request assistance in residents shared room. The form further documented that resident 209 was moved to a private room with staff supervision and the police department and Adult Protective Services were notified. A Social Services Summary, dated 8/1/23 at 9:39 AM, indicated, Resident has experienced trauma this last week due to a roommate. IDT was held for Resident with daughter to see additional support needed. So far rt [resident] has not shown deference from baseline. Outside support has been offered and denied multiple times from [resident 409]. Referrals were made to [Behavioral Health Service] and NP so that they are available for help. Staff have states that [resident 409] has shown no emotions that are different then from before trauma. A Social Services Progress Note, dated 8/1/23 at 3:58 PM, indicated, PSYCHOSOCIAL ASSESSEMENT [sic]: Pt has limited ability to answer questions. He is able to answer yes and no as long as he is allowed time for response. Pt was asked questions about emotional and mental health. Pt has expressed sadness about the incident from night before. Pt acknowledges he is not angry just sad. Pt has acknowledged that he would like to see someone . A Nursing Progress note, dated 8/2/23 at 11:16 AM, indicated, Resident was visited by two [city name redacted] City Detectives regarding incident with previous roommate on night of 7/31 [23]. Resident gave permission to talk to officers but appeared uncomfortable when questioning proceeded to more detailed questions. Nurse asked resident if he wanted to talk to me without them and he said yes. Resident then stated that 'He touched me. He shouldn't have done that.' I asked him if it was without his permission, if it made him uncomfortable, resident responded yes to both questions. I then asked resident if I could tell the officers what he just told me and he responded yes. Officers were informed of conversation. Wctm [will continue to monitor]. Review of the Form 359: Follow-Up Investigation Report, dated 8/7/23 at 9:20 PM, indicated, P't [sic] has limited ability to answer questions. He is able to answer yes and no as long as he is allowed time for response. Pt was asked questions about emotional and mental health. Pt has expressed sadness about the incident from night before. Pt acknowledges he is not angry just sad. Pt has acknowledged that he would like to see someone. Pt will be referred out for mental health services. [Behavioral Health Service] is 2-3 weeks referral. Psych [psychiatric] NP will be in facility next week which both referrals will be made. Follow-up conversation on 8/7/23, resident confirmed this was not a consensual act. The document further indicated, .[Resident 409] also has a history of depression. [Resident 409] capability to meaningfully answer and participate in the BIMS and PHQ9 [Patient Health Questionnaire-9] assessment process depends largely on his status on any given day; his cognitive level fluctuates. Sometimes he is able to answer the basic questions, and other times he does not answer at all. He requires extensive assist with ADL's [activities of daily living] and wheelchair use . The document further indicated, Abuse allegation verified-in follow up interviews with [resident 409], he confirmed that the incident was not consensual. The facility passed this information on to the [city name redacted] Police Department; [Resident 209] has been removed from the Facility in the custody of the police. The document further indicated, [Staff name redacted] worked the adjacent hall on the night of the incident. [Staff name redacted] re-counted the events that [Staff name redacted] reported; specifically, she confirmed that [resident 409] frequently masturbates and that the staff have been instructed to provide him privacy when he experiences that need . The document further indicated, .[resident 409] is known to masturbate often, even when staff are in the room . A Social Services Progress Note, dated 8/8/24 at 3:48 PM, indicated, Follow up with pt evening of 8/7/2023 on incident from previous week. Nursing has continually monitored Pt for change in physical, mental, or emotional health. Pt is documented to be at baseline. Met with pt this last evening to assess psychosocial wellbeing. Pt was able to discuss to verbalize multiple answers tonight. Pt has acknowledged that he is angry, sad, or frustrated over situation with roommate. He is happy that roommate is no longer in facility. Pt answered questions about daughter, birthyear [sic]. Pt laughed over a few jokes agreeing that SW [Social Worker] is able to come back to visit. Pt is selective on who he talks with it is very limited. Pt was offered mental health services which he declined. Pt was offered someone to talk to pt declined. Facility will continue to monitor for change in mental, physical, or emotional health. A Social Services Progress Note, dated 8/22/24 at 8:42 PM, indicated, Pt receive3d [sic] mail today about upcoming court procedures over past roommate. Pt does not want to know about upcoming hearings unless the court needs him. Resident 409's care plan revealed a focus of, Potential to demonstrate physical behaviors aeb [as evidenced by]: masturbation. Date Initiated: 12/04/2023. It indicated the Goal, Will not harm self or others through the review date. Date Initiated: 12/04/2023. And included the following interventions, Ensure hand hygiene is reminded and carried out frequently throughout the day. Date Initiated: 12/04/2023. Monitor/document/report to MD of danger to self and others. Date Initiated: 12/04/2023. Provide privacy via curtains and blankets/sheets as needed. Date Initiated: 12/04/2023. 5. Resident 209 was admitted to the facility on [DATE] with diagnoses which included [NAME]'s Encephalopathy, frontal lobe and executive function deficit, hypertension, alcohol use unspecified with alcohol-induced persisting amnestic disorder, major depressive disorder, cognitive communication deficit, and personal history of other mental and behavioral disorders. Resident 209's medical record was reviewed from 10/7/24 through 10/21/24. An admission MDS assessment dated [DATE], indicated resident 209 had a BIMS score of 9 which suggested moderate cognitive impairment. The Hospital History and Physical (H & P), dated 5/23/23, indicated: a. A Progress Note Generic, dated 4/24/23 at 10:05 AM, indicated, .4. History of violent behavior Mental status at baseline. He does have a history of violence, including strangling previous RN [Registered Nurse] at his facility, beating up her roommate. He is currently calm and not showing signs of agitation or aggression. Has hand [sic] several ER [emergency room] visits and admissions in last 6 months for violent behavior at care facility. Seen by psychiatry multiple time, neuropsychiatry 10/5/22- these providers/noted indicated that patient has significant impairment, concerns about decision making . b. A Behavioral Health Progress Note, dated 4/24/23 at 1:11 PM, indicated, Based on his history, patient is likely a at chronic risk of harm due to other. Violence seems to have co-occurred with the emergency of his neurocognitive deficit . An Encounter Progress note, dated 5/24/23 at 12:00 AM, indicated, [Resident 209] isa [sic] [AGE] year-old patient who is seen today as a new patient. He was admitted from [facility name redacted] Hospital. He has known cognitive deficits, history of alcohol abuse resulting in Warnicke Korsakoff syndrome. There was mention of a TBI [traumatic brain injury], but [facility name redacted] Hospital could not find in the actual records of this. He was found wandering the streets in the rain and confused. He was taken to the emergency room by police. He had previously been in [facility name redacted] but was discharged to a facility after violent behavior to the staff. He was transferred to [facility name redacted] Hospital for psychiatric consultation if needed. He has been in and out of facilities for many years, he is alert to self only today, is unsure where he is at or the appropriate year. He is currently laying in bed and appears cooperative. He had previously been on estrogen for hypersexuality, this was stopped at the hospital as that is not an appropriate indication, he is on paroxetine which should be helpful. He does have a sister who it appears has been fairly involved in his care. He takes trazodone at night to help him sleep, psych recommended this be used for aggression. He has also been on Eliquis which appears to have been since 2018 for bilateral PEs [pulmonary embolism]. This has been maintained. He is not able or capable of making his own decisions, had previously been at facilities, will be maintained in the secure memory unit, will have low threshold to intervene with behaviors due to his violent history. A Nursing Progress note, dated 5/24/23 at 5:19 AM, indicated, ALERT CHARTING: 72 hour admit charting Pt appears to be adjusting well to change. No negative or depressive statements made this shift. Pt has made 2 sexually suggestive comments to CNAs. Will continue to monitor pt for any changes in behavior. A Social Service Summary, dated 6/5/23 at 6:06 AM, indicated, [Resident 209] is admitted to facility for long term care in memory care. [Resident 209] is a [AGE] year-old male that is poor historian with history of frontal lobe/executive function deficit, neurocognitive deficit, TBI, [NAME] Korsakoff syndrome who was brought to the EDultimately [sic] ER after found wandering streets in the rain knocking on his whole childhood home store. He has been in and out of facilities for the last few years with admits to the ER due to violence incidents. His brother is currently seeking guardianship through court order. [Resident 209] has no plans for discharge at this time. A Nursing Progress Note, dated 6/7/23 at 1:14 AM, indicated, Pt flipped off nurse after nurse redirected him to his room. A Nursing Progress Note, dated 6/11/23 at 7:28 PM, indicated, CNA reported to LN [licensed nurse] that fellow female pt had wandered into pt's room and pt was inappropriate while touching fellow pt's shoulder and touching her hair. CNA immediately pulled pt out of the room and closed the door told pt he was very inappropriate. A Nursing Progress Note, dated 7/1/23 at 2:15 AM, indicated, Resident to Resident. Patient hit [name redacted] on her hand with his fist. When [name redacted] was trying to reach a pencil of color. After that he insult her with sexual vulgar words and telling her the F and B word. Continue monitoring [resident 209] aggressivity to avoid harmto [sic] another patient. An IDT Progress Note, dated 7/21/23 at 4:28 AM, indicated, IDT team has met to discussed pt. IDT will hold IDT Care plan meeting with family to discuss placement to other facility with the intentions to benefit the resident to help decrease behaviors. A Nursing Progress Note, dated 7/21/23 at 10:54 PM, indicated, Resident used foul language at nurses aides when they refused to get him more ice/water. This nurse asked nicely for resident not to use such language. Resident used more foul language at me and then stood up to try to intimidate me continuing to curse. Resident directed to his room. No further incidents noted. A Nursing Progress Note, dated 7/23/23 at 1:19 AM, indicated, At 2230 [10:30 PM] hrs [hours] patient arrive to the nurse station demanding the phone because he said he needed to call his Father. The nurse kindly mentioned that it was too late to call family. Also, we mention that tomorrow morning will be a better time to try that. He got furious and stated [sic] to using foul language saying the 'F' word and insulting the nurse calling her by the 'B' word. He also flipped the middle finger to her and alluded sexual offences. Then he left back to his room. A Nursing Progress Note, dated 7/23/23 at 1:38 AM, indicated, Resident to resident: Resident continue with sexual insinuations towards female residents. He was also passing in the hall way and many times he stop outside of the female resident's door and look around if someone was watching. Since he noticed that I was keeping my eye on him he did not enter in the room. Continue monitoring. An IDT Progress Note, dated 7/25/23 at 3:00 PM, indicated, Per staff and IDT discussion on 07/25/2023, on 07/21/2023 [resident 209] had asked female resident for sexual favors in which she denied and he left her alone regarding any additional sexual acts. Female resident was safe and unharmed and did not appear to be in any emotional distress, and [resident 209] was redirected. [Resident 209] continued to be monitored over the next several shifts, and was noted by LN on shift to be making sexual insinuations towards female residents, per the LN on shift no female resident was directly spoken to or harmed, [resident 209] was using hand and mouth gestures at female residents in the hallway insinuating oral stimulation of the penis. LN was right behind [resident 209] at the time and redirected him immediately. Resident continued on additional monitoring, staffaware [sic] of increased behaviors and to monitor resident closely and re-direct as indicated. SS [Social Services] and MD aware. A Nursing Progress Noted, dated 8/2/23 at 10:44 AM, indicated, Resident had 2 [city name redacted] City Police Detectives visit him regarding incident involving previous roommate in room [ROOM NUMBER]. Resident was read his rights and stated that he would 'listen to what they had to say.' After detectives informed him of potential charges against him, resident refused to answer any questions. Detectives left room and called an officer to arrest him. Officer arrived several minutes later and detained resident. Resident walked out of facility with officer. On 10/21/24 at 10:53 AM, an interview was conducted with the DON. The DON stated that resident 209 was initially admitted to the locked unit in his own room due to being an elopement risk. The DON stated that on 7/31/24, resident 209 was moved out of the locked unit and placed in a shared room with resident 409. The DON stated resident 209 was placed with a male roommate because he had not had any male-to-male incidents at all. The DON stated she was not sure if resident 209 was on frequent monitoring. The DON stated that resident 409 had masturbation behaviors. The DON stated that a staff member walked into the patient room and resident 209 was beside resident 409's bed and was assisting resident 409 in masturbation. The DON stated staff immediately separated resident 209 from resident 409 and moved resident 209 into a room by himself. On 10/21/24 at 12:09 PM, a follow up interview was conducted with the DON. The DON stated resident 409 was a one to two person transfer and could not get out of bed on his own. The DON stated they knew about his masturbation habits and that the room had a privacy curtain. The DON stated resident 409 did not know to provide privacy and would openly masturbate. The DON stated that staff had to close the curtain or the door to maintain resident 409's privacy. The DON stated they were not aware of the information provided in the Hospital H & P dated 5/23/23, for resident 209. The DON stated the facility had since revised the admission referral process and that clinical resources and social services had to review the resident's hospital paperwork. The DON stated they would not have accepted resident 209 as a resident based on the new admission referral process. Based on observation, interview, and record review, the facility did not ensure that residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation. Specifically, for 7 out of 69 sampled residents, residents were having consensual relationships per their families consent and the residents were not assessed and did not have the capacity to consent and residents were being sexually abused by other residents. Resident identifiers: 50, 70, 208, 209, 310, 311, and 409. Findings included: 1. Resident 70 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic kidney disease stage 2, dementia, essential hypertension, mild protein-calorie malnutrition, dysphonia, history of falling, cognitive communication deficit, major depressive disorder, and fall on same level. Resident 70's medical record was reviewed from 10/7/24 through 10/21/24. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 70 had a Brief Interview for Mental Status (BIMS) score of 10. A BIMS score of 8 to 12 indicated moderate cognitive impairment. On 9/1/23 at 12:12 PM, a Nursing progress note documented Note Text : Pt [patient] found by OT [Occupational Therapy] in his room with his pants off and female resident sitting beside him on the bed. OT assisted pt in getting pants on and assisted pt to the dining room. On 9/1/23 at 12:39 PM, a Nursing progress note documented Note Text : CNA [Certified Nursing Assistant] found pt standing behind the curtain with female resident. CNA brought both pt out of the room and to the dining room for lunch. On 9/6/23 at 11:24 AM, a Nursing progress note documented Note Text : Patient is being friendly and having relations with another female resident on the unit. Family is aware and patient is his own power of attorney per nursing management pt is ok to continue relations. Pt was found in his room with pants down and female resident in room. Both parties are in agreement to the situation. Since then both patients have been separate on the unit per their own accord. No concerns at this time, will continue to monitor. A care plan Focus dated 9/18/23, documented RESOLVED: I have a special friend I like to spend time with. We like to hold hands and kiss but sometimes forget that others become uncomfortable when we're in in [sic] public areas displaying affection. - Displaying affection toward resident [resident 208]. He consented with the affection and resident [resident 208] son aware and no concern. - Huddle/Inservice to facility employee in the unit. The Interventions initiated on 9/18/23, included: a. Anticipate and meet needs. b. Approach in a calm manner. c. Assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. d. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. e. If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. f. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. g. Provide a program of activities that is of interest and accommodates residents status. h. When displaying affection, staff to talk with parties involved to ensure all are consenting. On 10/10/24 at 4:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the resident associated with resident 70 during the incident on 9/1/23, was resident 208. The DON stated the incident was not reported because the incident was identified as a consensual relationship, between resident 208's family and resident 70 being his own power of attorney at that time. 2. Resident 208 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, essential hypertension, depression, and mild protein-calorie malnutrition. Resident 208's medical record was reviewed from 10/7/24 through 10/21/24. An admission MDS assessment dated [DATE], documented that resident 208 had a BIMS score of 99 which indicated resident 208 was unable to complete the interview. On 8/29/23 at 4:50 PM, a Nursing progress note documented Late Entry: Note Text: Resident was found in male residents room sitting on bed. Redirected resident and male resident to join day room activities. Despite the redirection, both residents continued to hold hands and have physical contact. Residents were separated during dinner time. (Note: The incident was with resident 70.) On 8/30/23 at 3:49 PM, a Nursing progress note documented Note Text: NO [new order] from provider to initiate Lexapro r/t [related to] hypersexual behavior secondary to Alzheimers [sic], as well as Pepcid 20mg [milligrams] BID [twice a day]. NO in place, representative aware. On 8/30/23 at 4:52 PM, a Nursing progress note documented Note Text: Resident was found by CNA in male residents room. Male resident did not have any pants or brief on, and female resident had her shirt pulled up some. Resident was removed from male residents room. She was then taken to the shower room, her hospice CNA came to do cares on her. DON notified of happenings. CNA staff aware to keep residents separated. (Note: The incident was with resident 70.) On 9/1/23 at 12:11 PM, a Nursing progress note documented Note Text: Pt found in fellow residents room sitting on the bed. OT found pt this way and brought pt out of the room. (Note: The incident was with resident 70.) On 9/1/23 at 12:35 PM, a Nursing progress note documented Note Text: CNA found pt standing behind the curtain with fellow resident. CNA brought both patients out of the room for lunch. (Note: The incident was with resident 70.) On 9/6/23 at 1:39 AM, a Nursing progress note documented Note Text: Pt was found in another pt's bed at 0130 [1:30 AM]. She was in the same pt's room that had a res [resident] to res situation on 9/4 [23]. No issues today, the other pt calmly reported to nurse that she was in his bed and asked the nurse to help her to her room. (Note: The incident was with resident 70.) On 9/6/23 at 11:21 AM, Nursing progress note documented Note Text: Patient is being flirtatous [sic] with a male resident on unit. They hold hands and pt is often found in male patients room. Earlier male pt was found on his bed with pants down while [resident name redacted] was in the room with him. Patients family is aware and per nursing management family is ok with patients behavior with this one male patient only, if she is to take a liking to any other resident we must notify her family. After pt was found with the other resident in his room they've been separate on the unit per their own accord. Will continue to monitor. (Note: The incident was with resident 70.) On 9/18/2023 at 7:19 PM, a Nursing progress note documented Note Text : patient found kissing another male resident in the male residents room patient was redirected into an activity 30 min [minute] checks started. (Note: The incident was with resident 50.) A care plan Focus created on 9/18/23 and initiated on 1/8/24, documented I have a special friend I like to spend time with. We like to hold hands and kiss but sometimes forget that others become uncomfortable when we're in in [sic] public areas displaying affection. - Resident displaying affection to resident [resident identifier redacted] and resident [resident identifier redacted]. - Son understand and aware of his mother affection with this resident. - Frequent Visual check and her whereabouts. - Huddle/Inservice staff q [every] change of shift to redirect resident. - Activities that catered to her needs to redirect her behavior. The Interventions created on 9/18/23 and initiated on 1/8/24, included: a. Anticipate and meet needs. b. Approach in a calm manner. c. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. d. If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. e. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. f. Minimize potential for resident's disruptive behaviors by offering tasks which divert attention. g. Provide a program of activities that is of interest and accommodates residents status. h. Staff to ensure when I am displaying affection towards others, that all parties are consenting. i. Stop and talk with resident when passing by. On 9/21/23 at 11:24 AM, an Interdisciplinary Team (IDT) progress note documented Note Text : IDT meet today unit managers/social worker and hospice to discuss about the incident that happened last 9/18/23. Resident was found kissing with resident [resident identifier redacted]. She wanders into his room, and both was redirected. Assisted resident back to activities and she stay in activities. Reported the incident to resident son and made aware. Hospice informed and plan to review her medication. Hospice plan to discuss with the son. Resident will be on q 30 mins [minute] checks and check her whereabouts. Plan activities that catered for her needs. Huddle with staff, Inservice about redirecting resident at all times. Continue as plan. Son aware and hospice informed. 3. Resident 50 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, vascular dementia, pain, essential hypertension, need for assistance with personal care, and cognitive communication deficit. Resident 50's medical record was reviewed from 10/7/24 through 10/21/24. A quarterly MDS assessment dated [DATE], documented that resident 50 did not have a BIMS score due to resident 50 rarely or never understood. On 9/18/23 at 7:21 PM, a Nursing progress note documented Note Text : a female resident found kissing [resident name redacted] in his room the female resident was redirected into an activity 30 min checks started family attempted to call left message DON and MD notified. A care plan Focus initiated on 9/18/23, documented RESOLVED: I have a special friend I like to spend time with. We like to hold hands and kiss but sometimes forget that others become uncomfortable when we're in in [sic] public areas displaying affection - Displaying affection with resident [resident 208] and he likes the affection, and his family was aware and with no concern. The other resident family also aware with no concern - Huddle/Inservice the staff to Redirect the resident and made aware of the plan. The interventions initiated on 9/18/23 included: a. Administer medications as ordered. Monitor/document for side effects and effectiveness. b. Anticipate and meet needs. c. Approach in a calm manner. d. Assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. e. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. f. Educate family/caregivers on successful coping and interaction strategies. Needs encouragement and active support by family/caregivers. Use these strategies. g. If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. h. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. i. Provide a program of activities that is of interest and accommodates residents status. j. When I am displaying affection towards others, ensure staff stop and ensure all parties are consenting. On 9/19/23 at 11:32 AM, a Social Services progress note documented Note Text : Spoke with PT niece today about incident of pt and other female resident kissing. Pt niece was understanding and consents for pt to have relations with another resident as long as he is happy. On 9/21/23 at 12:03 PM, an IDT progress note documented Note Text : IDT meet today. Clinical resource, Unit managers, SSD [Social Services Director] and SSD to discuss the incident that happened last 9/18/23. Resident was found kissing another resident [resident identifier redacted] in his room. Both was redirected. Reported this incident to resident niece and she was laughing because the resident already told her about it. No concern at this time. Will continue to monitor. NP [Nurse Practitioner] made aware of the incident. On 10/16/24 at 11:37 AM, an interview was conducted with the Medical Director (MD). The MD stated that sometimes he was involved with the capacity to consent for residents but it would depend on the situation with the resident. The MD stated that he would get help from psychiatry if the residents were in and out or questionable. The MD stated if there was going to be something legally he would get more opinions. The MD state if the capacity to consent affected anything medical the facility staff would consult with him. The MD stated that he was not consulted on the interaction with resident 70 and resident 208. The MD stated if he was consulted he did not document on either of the residents. The MD stated if the resident had behavioral health services they would usually follow the resident and not him. The MD stated if the residents were on the dementia unit he would expect to be consulted. The MD stated if the resident had no cognitive impairment, diagnoses, disability, or a BIMS score that would have triggered the decision the residents should have the capacity to consent. The MD stated if the residents were on the regular unit and there was a question about capacity he might call in someone else. The MD stated that the residents had a personalized screening for consent. On 10/[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 54 sampled residents, that the facility did not provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs). Specifically, a resident did not receive help with feeding assistance and cueing. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. Findings include: Resident 244 was admitted to the facility on [DATE] with diagnoses that included but not limited to gastro esophageal reflux disease, muscle weakness, major depressive disorder, anxiety disorder, and insomnia. Resident 244's medical record was reviewed on 1/24/23. An annual Minimum Data Set (MDS) assessment dated [DATE], documented that resident 244 required supervision assistance with one person. In addition, a quarterly MDS assessment dated [DATE] documented that resident 244 had a Brief Interview for Mental Status (BIMS) score of 15. A Plan of Care problem with an effective date of 1/4/17 documented that resident 244 required extensive assist with bed mobility, transfers, . eating, toilet use and personal hygiene. Another care area identified with an effective date of 1/24/17 documented that resident 244 was at nutritional risk as evidence by periods of decreased oral intake. An intervention implemented on 1/1/18, documented that resident 244 would have weekly weights x 30 days and monthly if stable and to promptly identify signs and symptoms of weight loss and dehydration; interventions initiated timely daily. [Note: no weekly weights were done.] Registered Dietician Nutritional Risk Review dated 12/22/22 documented that resident 244 had an 8% (percent) weight loss since 11/2/22. A nurse practitioner/ physician assistant progress note dated 8/25/22 documented that resident 244 had some noted weight loss recently due to food preferences. A nurse practitioner/ physician assistant progress note dated 12/27/22 documented that resident 244's sister expressed concerns on 12/7/22 about resident 244's difficulty eating and stated it took resident 244 a long time to eat the food that he had so far. A new patient encounter progress note dated 1/3/23 documented that resident 244 had reportedly been losing weight. On November 2 he weighed 187 pounds, today he weighs 168 which is a 10% weight loss. He states his appetite has not been very good as he just has not felt well. He remains at risk for significant weight loss and malnutrition. The exact meal percentage consumption for the last 30 days documented that resident 244 had consumed 50 % or less of his meals for 46 out of 72 documented encounters. The snack consumption for the last 30 days documented that resident 244 accepted a snack 3 times out of the 24 instances documented. On 1/23/23 at 10:25 AM, resident 244 was observed sitting up in his bed with his eyes closed. A breakfast meal tray was observed on a bedside table in front of resident 244. Most of the food on the breakfast tray appeared to be untouched except, for the cereal. On 1/25/23 at 12:05 PM, resident 244 was observed to have his eyes closed when his lunch tray was dropped off. The lunch tray was observed on a bedside table located to the right of resident 244. Resident 244 eye's continued to appear closed until 12:16 PM. On 1/25/23 at 1:47 PM, resident 244 was observed to have his eyes closed and lunch tray at bedside remained untouched. On 1/26/23 at 10:00 AM, resident 244 was observed to have his eyes closed and had a napkin placed across his chest with a handful of cheerios scattered across the napkin. A breakfast meal tray was observed on a bedside table in front of the resident. The breakfast meal tray had a piece of toast with jelly, a cut up sunny side up egg and a bowel of cheerios. The cheerios were the only item of food that was touched by the resident. On 1/26/23 at 12:10 PM, resident 244 was observed to be sitting up in bed and staring at his food with shaking hands. A lunch tray compromised of meat and rice was observed on a bedside table located in front of resident 244. Resident 244 continued to stare at his food for 17 minutes before he picked up his cup of milk with a shaky hand. Resident 244 was observed to bring the cup of milk to his mouth without spilling but began to cough when he drank the milk. Resident 244 was then observed to spill the remainder of his milk as he tried to put the cup back on his bedside table. A follow up interview was conducted with resident 244. Resident 244 stated he did not like his food, and he did not plan to eat it. Resident 244 stated the only thing he liked was the milk and that he was not hungry. On 1/26/23 at 1:17 PM, resident 244 was observed to have his eyes closed and his lunch tray appeared to be untouched expected for the milk he drank. On 1/30/23 at 12:07 PM, resident 244's sister was observed to feed resident 244 homemade soup. A follow up interview was conducted with resident 244. Resident 244 stated he needed help feeding himself. Resident 244 stated that staff took his meal trays away and had not offered him any meal substitutions when he did not like the food. On 1/26/23 at 11:15 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated the resident 244 was an extensive two person assist and needed to be pulled up in bed for every meal. CNA 3 stated that resident 244 ate in his room and that he was capable of feeding himself. CNA 3 stated that the only help resident 244 required with meals was to have his tray set up for him. CNA 3 stated they were unsure the percentage of his meals that he ate. On 1/25/23 at 12:34 PM, an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated that resident 244 was able to feed himself and only required setup assist with his tray. The MDSC stated that resident 244 didn't always eat all his food because he didn't like what he was served. The MDSC stated that resident 244 got a boost with all his meals as a supplement. On 1/26/23 at 10:46 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 244 ate about 25% of his breakfast today. CNA 2 stated resident 244 didn't eat very much of his meals. CNA 2 stated that resident 244 was capable of using silverware and was able to feed himself and did not require any help that he was aware of. On 1/26/23 at 12:35 PM, an interview was conducted with the Occupational Therapist (OT). The OT stated they had not worked with resident 244 since October. The OT was asked if resident 244 was able to feed himself with his shaky hands and the OT responded that they were unsure how much help resident 244 needed with meals. The OT stated they evaluated and worked with residents that needed more assistance on ADLs. The OT stated they were not working with resident 244 since he didn't need help with any ADLs that he was aware of. On 1/30/23 at 11:11 AM, an interview was conducted with Licensed Practical Nurse (LPN)1. LPN 1 stated that resident 244 was able to feed himself and was able to reach for his own waters. LPN 1 stated that every once in a while, resident 244 did not each much but stated that he always ate his cereal. On 01/30/23 at 12:21 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that resident 244 was a set up assistance for meals. The CNAC stated they made sure to sit him up in bed and during brief changes. The CNAC stated she handed resident 244 his chocolate milk with meals and stated that resident 244 did not have problems grabbing thing with his hands. The CNAC stated there were times where he did not eat his food because he did not like what was serve to him. The CNAC stated that resident 244 verbalized when he did not like his meal. The CNAC stated they have asked resident 244 if he needed help with meals but stated that resident 244 has refused the help. The CNAC stated they thought it was weird that resident 244's sister was feeding him lunch today because resident 244 was able to feed himself and did not that much help with meals. On 1/30/23 at 3:56 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that supervision assist meant that a staff member had to help and encourage the resident to eat during meals. The DON stated if the resident's MDS documented him as a supervision assist, she expected staff to be at bedside during mealtimes to help feed him. The DON that when a resident has a 10% weight loss, they were triggered for weight loss and put on weekly weights, as well as reviewed in the weekly Nutrition at Risk meetings. [Cross refer to F692]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 295 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included sepsis, urinary tract infection, extended spectrum beta lactamase resistance, quadriplegia, hypertension, gastroparesis, malnutrition, ileostomy status and cachexia. On 1/23/23 at 10:00 AM, an interview was conducted with resident 295. Resident 295 stated he wished he could have a more thorough bed bath when he got one. Resident 295 stated he didn't get one very often, maybe once a week. Resident 295 stated a bed bath more often might be nice. An observation was made of resident 295. Resident 295's hair was oily, combed back, and large amounts of dandruff were observed in resident's 295's hair. On 1/24/23, resident 295's medical record was reviewed. Review of resident 295's bathing task for the last 30 days revealed resident 295 was not available on 12/28/22 (resident was in the local hospital), resident refused on 1/4/23, and resident refused on 1/23/23. All other dates were marked with not applicable (N/A) which meant per the certified nurses aides (CNA's) this task was not performed. On 3/12/22 a baseline care plan documented that resident 295 was at risk for alterations in Activities of Daily Living (ADLs) due to weakness, decline in function and mobility, bowel obstruction, status post-surgery and quadriplegia. An intervention documented resident required staff participation with bathing. An MDS dated [DATE] revealed resident 295 was totally dependent on staff with the bathing task and required substantial/maximal assistance with showering/bathing. Review of resident 295's bathing task revealed the residents bathing preference was day (AM), evening (PM) with as needed (PRN) night (NOC). Resident 295 had a shower schedule of Mondays, Wednesdays, and Fridays. Resident 295's shower/bathing history for the month of October 2022 revealed: a. 10/5/22 Sponge bath b. 10/7/22 Resident refusal c. 10/12/22 Sponge bath d. 10/19/22 Sponge bath e. 10/26/22 Resident refusal No resident refusal forms were provided by the facility for the 10/7/22 or 10/26/22. Resident 295 went 13 days from when a bath refusal was documented on 10/26/22 to when another bath was offered on 11/8/22. Resident 295's shower/bathing history for the month of November 2022 revealed: a. 11/8/22 Resident refusal b. 11/16/22 Resident refusal c. 11/23/23 Sponge bath d. 11/30/22 Resident refusal No resident refusal forms were provided by the facility for the month of November. Resident 295 went 14 days from when a bath refusal was documented on 11/30/22 to when a bath was documented on 12/14/22. Resident 295's shower/bathing history for the month of December 2022 revealed: a. 12/14/22 Sponge bath b. 12/21/22 Resident refusal c. 12/28/22 Resident unavailable (resident hospitalized ) No resident refusal forms were provided by the facility for the month of December. Resident 295's shower/bathing history for the month of January 2023, up until the survey date, revealed: a. 1/4/23 Resident refusal b. 1/23/23 Resident refusal A resident refusal form for 1/23/23 was not provided by the facility. On 1/26/23 at 12:40 PM, an interview was conducted with CNA 2. CNA 2 stated resident 295 was always good with cares and taking his bath, he was cooperative. CNA 2 stated he thought resident 295 was scheduled 2 or 3 times a week for a bath. CNA 2 stated resident 295 usually wouldn't ask for things so they had to anticipate his needs. On 1/30/23 at 1:10 PM, an interview was conducted with the CNA Coordinator (CNAC). The CNAC stated the CNAs were assigned to an area when they come on shift, and some CNAs did showers and some did resident care. The CNAC stated that the CNAs had a shift sheet which gave them information on the residents, and it included if residents were an every 2 or 4 hour turn, when their bath was and other needed information. The CNAC stated that the facility had a concierge service that did not do resident care but helped with getting waters, cleaning equipment and other things so the CNAs had more time with the residents. The CNAC stated that CNAs were expected to complete the tasks, including baths, that they were assigned for their shift and if they were unable to do this they were supposed to pass this information on to the oncoming shift. On 1/30/23 at 3:27 PM, an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) 1. The DON stated the CNAs were supposed to shower the residents on their scheduled shower days, unless the resident refused then the CNA was supposed to offer another day. The CNAs were supposed to have the residents sign a refusal form every time they refused a shower. The ADON 1 stated the residents' shower days were in the care plan so the CNAs and the nurses knew when they were and treatments could be coordinated if needed. [Cross refer to F867] Based on interview, observation and record review, the facility did not ensure that 4 of 54 sample residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, residents were not assisted with toileting or bathing as needed. This resulted in a finding of harm for one resident. Resident identifiers: 27, 60, 295 and 349. Findings include: HARM 1. Resident 27 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, Parkinson's disease, neurocognitive disorder with Lewy Bodies, neuropathy, and insomnia. Resident 27's medical record was reviewed on 1/23/23. Resident 27's quarterly Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The MDS indicated that resident 27 was severely cognitively impaired. The MDS indicated that resident 27 required extensive assistance of two people for bed mobility, transferring, dressing, and toilet use. The MDS indicated that resident 27 required extensive assistance of one person for personal hygiene and bathing. The MDS further indicated that resident 27 was unable to move on and off the toilet without staff assistance. The MDS also indicated that resident 27 was always incontinent of bladder, and frequently incontinent of bowel. And the MDS also indicated that resident 27 was at risk for pressure sores, and currently had Moisture Associated Skin Damage (MASD). On 2/8/22 facility staff developed a care plan for resident 27 indicating that the resident had an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Immobility secondary to Parkinson's disease, impaired cognition secondary to Dementia with Lewy bodies . The goal listed was to safely perform bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Interventions on the care plan included Requires Extensive assistance staff participation to use toilet, Requires Extensive assistance staff participation with transfer, and Requires Extensive Assistance staff participation to reposition and turn in bed. On 11/11/22 facility staff developed a care plan for resident 27 indicating that he had MASD to his sacrum related to incontinence. The care plan goal indicated that resident 27 Will be free from MASD through the review date. Interventions included encourage good nutrition and hydration in order to promote healthier skin, identify potential causative factors and eliminate/resolve, when possible, reposition frequently, treatment as ordered, and wound nurse to follow. Resident 27's medical record indicated that from 1/1/23 through 1/29/23, resident 27 required extensive assistance or was totally dependent on staff for bed mobility 69 of 79 opportunities. On 10/20/22 a weekly skin evaluation indicated that resident 27 has reddened Non blanchable area to his LT (left) buttock. Area was cleaned and barrier cream applied. [Note: No documentation could be found to indicate that the wound nurse had observed the wound until 11/11/22, approximately 22 days later.] On 10/29/22 a nurses note documented, Coccyx with open area. Wound care tech came and treated wound. Cleaned wound Anasept applied then dressing. Wound care nurse was notified. [Note: The first wound note was not entered until 11/11/22, approximately 14 days later.] On 11/10/22 a nurses note documented, Pt (patient) continues to area (sic) to buttocks that is no (sic) blanchable. I had informed the MD in the past about this area. We have applied barrier cream and bridged him while in bed. I have informed the wound CNA (Certified Nursing Assistant) about area. On 11/11/22 a nurses note documented, Wound care team assessed sacrum, 2.3 [centimeter (cm)]x (by)3.1xUTD (unable to determine) open area with redness in surrounding tissue wound bed is 40 slough, 30 granular, 30 macerated. entire area is blanching. On 11/16/22 resident 27 was assessed by a Physician Assistant-Certified (PA-C). The PA-C documented that the resident had MASD on his sacrum that had been present longer than one week. The size of the wound was documented as 2.3 cmx3.1 cm x UTD, with 90 percent granulation and 10 percent slough. The PA-C documented that the Tissue does blanch. The PA-C indicated that with each brief change, staff were to remove resident 27's dressing, cleanse the wound, apply skin prep to periwound, apply Medihoney to wound bed, and cover with Bandage. On 11/17/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that resident 27 had MASD to his sacrum that was 2.3x3.1xUTD . Patient has new MASD that is open, initial visit with wound provider this week, debrided with a curette to remove slough and macerated edges. Patient has barriers in wound healing of cognitive impairment and incontinence. MD (medical doctor) and family notified. On 11/18/22 a nurses note documented, Wound note MASD to sacrum wound nurse to call family. On 11/23/22, a Skin Ulcer Non-Pressure Weekly assessment was initiated for resident 27 but was left blank. On 11/23/22, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound had increased in size and measured 2.5x3.4xUTD. On 11/28/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that the wound had increased in size and measured 2.5x3.4xUTD. On 12/5/22, resident 27 was assessed by a PA-C. The PA-C documented that Selective debridement due to slough today; 50 [percent] granular tissue with granular buds noted post debridement. Continue with current treatment. Pt is soiled today. On 12/12/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that the wound was unchanged in size from 11/28/22. On 12/14/22, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound measured 2.4x3.6xUTD. The periwound was described as Macerated. The PA-C documented that Sizes slightly larger after last week's debridement with increased granular tissue. Continue treatment. On 12/21/22, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's sacrum had increased slough, so selective debridement was completed. On 12/28/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that resident 27's wound measured 2.1x2.5xUTD. On 1/1/23 a nurses note documented, Resident has ongoing pressure wound to coccyx, difficult for resident to turn on side. Has pressure reducing mattress in place. On 1/4/23, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound measured 1x2.1x0.3. On 1/11/23, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound measured 1.5x2.3x0.3, which indicated the wound had increased in size. On 1/27/23, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that the wound had not changed in size since 1/11/23. No documentation was located to indicate what days and times, if any, resident 27 refused to be repositioned or have his brief changed. On 1/30/23 at 11:30 PM, an observation was made of the Wound Nurse (WN) and CNA 2. The WN and CNA 2 were observed to enter the room of resident 27. Resident 27 was lying in his bed. The WN raised the resident's bed to approximately waist height and both the WN and CNA 2 pulled resident 27 toward the edge of the bed. The WN and CNA 2 then walked out into the hallway to obtain hand sanitizer. No side rails were observed to be pulled up on the bed, as resident 27 was lying on his right side, with his back near the edge of the bed, unattended by staff. The WN and CNA 2 returned to the bedside of resident 27 and donned gloves. The WN pulled back the soiled brief, and blood was observed on the brief. No dressing was observed on the wound. The WN cleaned the wound on resident 27 with dry gauze. Resident 27 said ouch as the wound was cleaned. The wound area had different shades of red, and dark red, neither area blanched when pressed on by the WN. The WN stated, We debrided last week, that's why it hurts. No pain alleviation was offered to resident 27. The WN again left the bedside to go to the hallway to obtain hand sanitizer. CNA 2 was standing at the foot of the bed with his back to the resident. While the WN was in the hallway, the soiled brief was observed to return to the original position and touch the cleaned wound. The WN donned gloves and returned to the bedside and repositioned resident 27 using the draw sheet on the bed. Her gloves were not observed to be changed. The WN applied ointment to a gloved finger then to the wound. The WN and CNA 2 were then called away to the doorway, the soiled brief again returned to its original position and touched the wound. The WN returned to the bedside, pulled the brief away from the wound and a new dressing was applied to the wound. The WN then put the soiled brief back in place over the new dressing on resident 27. At that time, both the WN and CNA 2 were observed to have left the room to obtain hand sanitizer, resident 27 was still observed to be close to the edge of the elevated bed with no side rails in position. Both staff then returned to reposition resident 27. On 1/30/23 at 11:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 8. When asked about resident 27, LPN 8 stated that staff were instructed to help the resident turn and keep him off his bum. LPN 8 stated that resident 27 did not get out of bed or attempt to get out of bed during the nighttime hours. LPN 8 stated that resident 27's sacrum wound was old and that it was caused by staff not repositioning the resident or changing his incontinence briefs timely. LPN 8 stated that in the recent past, there would only be one CNA assigned to the memory care unit, which was not enough to ensure the safety and good care of the residents. POTENTIAL FOR HARM 2. Resident 60 was admitted to the facility on [DATE] with diagnoses that included dementia, cognitive communication deficit, diabetes mellitus, anxiety disorder, right hand contracture and muscle weakness. Resident 60's medical record was reviewed on 1/23/23. Resident 60's annual MDS assessment dated [DATE] was reviewed. The MDS indicated that resident 60 was severely cognitively impaired. The MDS indicated that resident 60 required extensive assistance with one staff member for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The MDS also indicated that resident 60 required extensive assistance with two staff members for transfers. The MDS indicated that resident 60 did not ambulate independently and required the use of a wheelchair. The MDS further indicated that resident 60 was unable to move on and off the toilet without staff assistance. The MDS also indicated that resident 60 was always incontinent of bladder, and frequently incontinent of bowel. The MDS also indicated that resident 60 was at risk for pressure sores, and currently had MASD. On 12/6/20 facility staff developed a care plan for resident 60 indicating that the resident had an ADL Self Care Performance Deficit r/t Immobility secondary to dementia . The goal listed was to safely perform bed mobility, transfers, eating, dressing, grooming toilet use and personal hygiene through the review date. Interventions on the care plan included Requires Extensive assistance 1-2 staff participation to . use toilet, Requires Extensive assistance 1-2 staff participation with transfers, and Requires Extensive Assistance 1-2 staff participation to reposition and turn in bed. On 1/6/21 facility staff developed a care plan for resident 60 indicating that resident 60 had bowel and bladder incontinence. Interventions included the use of disposable briefs for resident 60, and that the briefs should be changed with rounds, cares and as needed. On 1/25/23 the following observations were made of resident 60: a. At 10:02 AM, the resident was seated in her wheelchair by the main nurse's station in the 100 hall. b. At 11:10 AM, staff wheeled resident 60 into the day room. c. At 12:23 PM, staff wheeled resident 60 from the day room directly to the dining room. d. At 1:42 PM, staff wheeled resident 60 from the dining room directly to the day room. e. At 1:51 PM, the observation ended. At no time during the continuous observation was resident 60's incontinence brief changed, nor was resident 60 repositioned. On 1/25/23 at 1:51 PM, an interview was conducted with CNA 14. CNA 14 stated that she was paired with CNA 15 that day. CNA 14 stated that they showered resident 60 at 6:45 AM that morning, but that they had not changed resident 60's incontinence brief after that. On 1/25/23 at 1:54 PM, an interview was conducted with CNA 13. CNA 13 stated that she and CNA 16 had changed resident 60's incontinence brief that morning before breakfast. CNA 13 confirmed that she had not changed resident 60's incontinence brief since that time. CNA 13 stated that she was about to do rounds again with CNA 16, and they would change resident 60's incontinence brief. On 1/25/23 at 1:57 PM, an interview was conducted with CNA 15. CNA 15 stated that resident 60 required extensive assistance of staff to change her incontinence brief. CNA 15 stated that the typical schedule was to change the residents' incontinence briefs when she arrived for her shift at 6:00 AM, then at 9:00 AM, before lunch, after lunch, and at 2:00 PM before she left her shift. CNA 15 stated that she and CNA 14 had changed resident 60's incontinence brief when they first arrived for their shift at 6:00 AM, but had not changed it since then. CNA 15 stated that CNAs assigned on the 100 hall did not have assigned residents, we just help each other and we communicate. On 1/25/23 at 2:19 PM, an interview was conducted with CNA 16. CNA 16 confirmed that he did not change resident 60's incontinence brief after the initial brief change that morning. On 1/25/23 at 2:11 PM, resident 60 was observed to be wheeled to her room by CNAs 14 and 15. 3. Resident 349 was admitted to the facility on [DATE] with diagnoses that included dementia, vascular dementia, diabetes mellitus, chronic kidney disease muscle weakness, cognitive communication deficit, history of transient ischemic attack, and chronic obstructive pulmonary disease. Resident 349's medical record was reviewed on 1/23/23. Resident 349's annual MDS assessment dated [DATE] was reviewed. The MDS indicated that resident 349 was severely cognitively impaired. The MDS indicated that resident 349 required extensive assistance with one staff member for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The MDS also indicated that resident 349 required extensive assistance with two staff members for transfers. The MDS indicated that resident 349 did not ambulate independently and required the use of a wheelchair. The MDS further indicated that resident 349 was unable to move on and off the toilet without staff assistance. The MDS also indicated that resident 349 was always incontinent of bladder, and always incontinent of bowel. The MDS also indicated that resident 349 was at risk for pressure sores. On 2/9/18 facility staff developed a care plan for resident 349 indicating that the resident had an ADL Self Care Performance Deficit r/t functional mobility, strength and reduced balance, dementia . The goal listed was to maintain current level of function in bed mobility, transfers, eating, dressing, grooming toilet use and personal hygiene through the review date. Interventions on the care plan included requires assistance (one person extensive) to . use toilet, Requries (sic) (one person extensive staff participation with transfers, and Requires extensive assistance staff participation to reposition and turn in bed. On 6/30/21 facility staff developed a care plan for resident 349 indicating that resident 349 had bowel and bladder incontinence. Interventions included the use of disposable briefs for resident 349, and that the briefs should be changed with rounds, cares and as needed. On 1/25/23 the following observations were made of resident 349: a. At 10:02 AM, the resident was seated in her wheelchair in the day room. b. At approximately 12:30 PM, staff wheeled resident 349 from the day room directly to the dining room. d. At 1:44 PM, staff wheeled resident 349 from the dining room directly to the day room. e. At 1:51 PM, the observation ended. At no time during the continuous observation was resident 349's incontinence brief changed, nor was resident 349 repositioned. On 1/25/23 at 1:51 PM, an interview was conducted with CNA 14. CNA 14 stated that she was paired with CNA 15 that day. CNA 14 stated that they showered resident 349 at approximately 6:25 AM that morning, but that they had not changed resident 60's incontinence brief after that. On 1/25/23 at 1:54 PM, an interview was conducted with CNA 13. CNA 13 stated that she and CNA 16 had changed resident 349's incontinence brief that morning before breakfast. CNA 13 confirmed that she had not changed resident 349's incontinence brief since that time. CNA 13 stated that she was about to do rounds again with CNA 16, and they would change resident 349's incontinence brief. On 1/25/23 at 1:57 PM, an interview was conducted with CNA 15. CNA 15 stated that resident 349 required extensive assistance of staff to change her incontinence brief. CNA 15 stated that the typical schedule was to change the residents' incontinence briefs when she arrived for her shift at 6:00 AM, then at 9:00 AM, before lunch, after lunch, and at 2:00 PM before she left her shift. CNA 15 stated that she and CNA 14 had changed resident 349's incontinence brief when they first arrived for their shift at 6:00 AM, but had not changed it since then. CNA 15 stated that CNAs assigned on the 100 hall did not have assigned residents, we just help each other and we communicate. On 1/25/23 at 2:19 PM, an interview was conducted with CNA 16. CNA 16 confirmed that he did not change resident 349's incontinence brief after the initial brief change that morning. On 1/30/23 at 3:37 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that facility CNAs were provided a sheet to document if a resident received a brief change, and how often they should be checked. The DON stated that facility staff should be checking residents' incontinence briefs every couple of hours. When asked how the facility management was ensuring that briefs were being changed timely, the DON stated that facility staff were asking the [CNAs] if they have done their brief changes. On 1/30/23 at 3:17 PM, an interview was conducted with the facility Administrator (ADM). The ADM was asked what interventions had been put into place since November 2022 when the facility was cited for F677 after multiple residents were identified as not having their incontinence briefs changed in a timely manner. The ADM stated that they the CNA Coordinator was reviewing the electronic health record documentation to ensure the staff were documenting brief changes. When asked if there was a specific auditing process in place, the ADM stated there was not. When asked if observations were being made by facility management to ensure brief changes were occurring versus being documented, the ADM stated that intervention had not been put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not ensure, for 1 of 54 sample residents, that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices. Specifically, one resident developed a penile wound and did not promptly receive appropriate wound care follow up and no investigation was done on the cause of the wound. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. Findings include: Resident 244 was admitted to the facility on [DATE] with diagnoses that included but not limited to gastro esophageal reflux disease, muscle weakness, major depressive disorder, anxiety disorder, and insomnia. Resident 244's medical record was reviewed on 1/24/23. A Plan of Care problem with an effective date of 1/4/17 documented that resident 244 required extensive assist for bed mobility, transfers, eating, toilet use and personal hygiene. An intervention implemented on 1/4/17, documented that resident 244 required skin inspections such as observing for redness, open areas, scratches, cuts and bruises. Another intervention implemented on 1/23/23 documented that resident 244 had actual impairment to his skin integrity related to trauma to penis. An intervention implemented on 1/23/23 documented resident 244 needed to be encouraged to have good nutrition and hydration in order to promote healthier skin. A physician order with a start date of 11/6/22 documented as followed, Wound care to top of penis, betadine and open to air every shift for trauma to penis. A nursing progress note dated 10/13/22 documented, Resident 244's sores around his penis are getting much worse. On the dorsal side it now looks like a hematoma has formed and he is complaining of extreme pain with brief changes . Needs to be followed up with wound care. [Note: Resident 244 was seen by wound care 13 days later on 10/26/22.] A physician progress note dated 12/1/22 documented that on 10/13/22 resident 244 had a dark red lesion to the lateral right aspect of his glans penis. There was no open lesion or drainage noted. The physician documented that lesions/sore appeared to be from friction and positioning. Wound care provider progress notes documented: a. Resident 244 was first seen by the wound care provider on 10/26/22 and identified resident wound was caused by trauma and stated the resident's penis had dark discoloration. b. Wound notes on 11/9/22, 11/16/22, 11/23/22, 11/30/22, and 12/7/22 stated that the wound was stable and the discoloration was lightening up. c. Wound note on 12/19/22 stated, Wound is getting smaller and there seems to be some hemosiderin staining without any open area. Continue current treatment plan. d. Wound notes for 12/28/22, 1/2/23, and 1/11/23 documented that the wound was stable and had improved as well as had decreased in size. Skin Ulcer non pressure weekly assessments revealed: a. On 11/6/22 it was documented that the onset of the penile wound was on 10/26/22. It stated that there was a dark discoloration to the trauma site at the top of the penis and that the wound was stable and there were no signs of infection. b. On 11/18/22 resident 244's penile wound was described as epithelial tissue that was dark red/purple and lightening up. c. On 12/12/22 it was documented that, wound continues to improve in discoloration continue iodine and open to air. Patient has barriers in wound healing of limited mobility, incontinence and wearing briefs due to incontinence. Weekly Skin evaluations dated 9/26/22, 10/10/22 and 10/31/22 revealed that resident 244's scrotal area was excoriated. No documentation could be located to indicate an investigation was completed regarding how resident 244 obtained the penile wound. On 1/30/23 at 8:55 AM, a wound observation was done on resident 244 while he got his brief changed. Resident was observed to be thin, no lines on the skin were noted from the brief being too tight. Resident 244's penis was noted to be in the center of peri area, pointing downward and the scrotal sac laid flat against the perineum. Resident 244's penis did not appear to have enough length to have been pinched in between either thigh. Certified Nursing Assistant (CNA) 4 was observed to hold the penis in his left hand and pulled the skin back, away from the head of the penis with his right hand. A ruby red area was noted on the resident's right side of the head of the penis; around the penis rim, the area had a center spot with spindles that came from the center area in every direction. The area was uniform in color. No drainage was noted and no open area noted to the penis. The same red discoloration was noted on the base of the scrotum in three different areas, one larger and two smaller areas. This was seen when resident 244 was rolled onto his left side and the buttocks area was viewed. The resident was rolled back to his back and the scrotum was lifted up; no other reddened areas were noted on the scrotum. Paste was applied to resident 244's buttocks and a brief was put under the resident. On 1/25/23 at 10:45 AM, an interview was conducted with CNA 7. CNA 7 stated that resident obtained his penile wound because he slid down in bed and sat on his penis. CNA 7 stated resident 244 has had this wound since November. On 1/25/23 at 10:48 AM, an interview was conducted with the Wound Physician Assistant (WPA). The WPA stated that resident 244 obtained his penis wound because the resident sat on it. The WPA stated when he first saw the penile wound, there was discoloration on it but stated that the color of it had improved. The WPA stated it was never an open wound but they applied betadine to protect his skin. The WPA stated resident 244's wound was stable enough that the nurses were applying betadine. On 1/30/23 at 8:55 AM, an interview was conducted with CNA 4 while he completed a brief change on resident 244. CNA 4 stated resident 244's penile wound happened because of the way resident 244 bent his legs that caused his penis to be pinched. CNA 4 was told it was a bruise and stated that resident 244's penis was black when he first saw it. CNA 4 stated he was unsure how long the penis was left in any certain position for it to have turned black. CNA 4 stated it was a significantly worse bruise when they discovered it back in December and stated the bruise was heading in the right direction since it had improved. CNA 4 stated they were told to keep a close eye on resident 244's penis and was told to notify the nurse if there were any concerns. CNA 4 stated they came in every 2 hours and repositioned resident 244. CNA 4 stated when a new brief was put on resident 4, they pulled the scrotum and the penis up in the center of the peri area and then put the brief in place. CNA 4 stated this was how the scrotum and penis were protected from being pinched. On 1/30/23 at 10:53 AM, an interview was conducted with the Wound Nurse (WN). The WN stated that resident 244's penile wound was due to a catheter he had while he was hospitalized . The WN stated that was what the wound care provider said at the initial evaluation of 244's penile wound on 10/26/22. The WN stated resident 244's wound had gotten smaller and the discoloration had lightened up. The WN stated the current wound care orders were to apply iodine to resident 244 penis. The WN stated the iodine helped lighten the bruising and it created a barrier that helped protect the skin. On 1/30/23 at 11:02 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 244 has had the penile wound for several for months. LPN 1 stated that it looked really bad when it was first discovered. LPN 1 stated that initially the resident's penis wound was tomato red in color. LPN 1 stated that resident 244 complained of a lot of pain when his wound was first discovered but stated he no longer complained of pain. LPN 1 stated the wound care nurse did the wound care on Mondays, Wednesdays and Fridays. LPN 1 stated the wound care orders were to apply betadine to resident 244's penis. On 1/30/23 at 12:26 PM, an interview was conducted with the Certified Nursing Aid Coordinator (CNAC). The CNAC stated that resident 244's skin appeared to be really thin and they were careful during brief changes to avoid any skin issues. The CNAC stated that resident 244 sometimes got a sore underneath his penis because of how sensitive and delicate his skin was. The CNAC stated she was not aware that resident 244 had a sore on his penis. The CNAC stated that when a new skin issue was discovered on any resident, their protocol was to notify the resident's nurse and wound nurse right away. The CNAC stated that resident 244 was able to reposition himself if he was uncomfortable but stated facility staff repositioned him every two hours. On 1/30/23 at 4:13 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 244's penile wound happened because the resident's penis was long and the resident sat on it. The DON stated that staff had to constantly go back and pull resident 244's penis out from underneath him. The DON stated wound care should have evaluated resident 244 sooner than 10/26/22. The DON stated that staff knew the protocol for getting the wound care nurse involved. The DON stated that if any staff noticed a wound, they notified the wound care nurse that same day. The DON stated she was unsure why there was a 13-day delay for wound care to see resident 244 and that no investigation was done on his penile wound. [Cross refer to F692]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for 3 of 54 sampled residents, that the facility did not ensure that the residents' environment remained as free of accident hazards as is possible. Specifically, one resident with a history of falls was left unattended and subsequently fell out of bed, receiving an eye laceration. The deficient practice for this resident was cited at a harm level. In addition, one resident with a history of falls was observed to not have interventions in place, and one resident was left unattended at the side of his bed. Resident identifiers: 27, 41 and 146. Findings include: HARM 1 . Resident 146 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, polyneuropathy, Parkinson's disease and generalized anxiety disorder. Resident 146's medical record was reviewed on 1/23/23. On 1/6/23 a Fall Committee note indicated that resident 146 had experienced 3 falls where she was found on the floor mat next to her bed. No injuries occurred . already in a low bed and a floor mat has been added. She has dementia and is not aware of her own safety. Will continue to try and keep her from having an injury but she will climb out of bed. An incident report dated 1/8/23 at 11:30 PM stated that, Pt (Patient) found lying face flat on the floor at 2330 (11:30 PM) yelling for help. When turned over to back pt (patient) had blood all over face two gashes found above and under right eye Gashes were heavily bleeding. Bruising on rt (right) eye and chin. Wound treated. Neuro status at baseline, awake and responsive with pupils dilating wnr (within normal range). Family contacted without success. Provider [Medical Director] notified and acknowledged. Pt to be sent to hospital for stitches and CT [computerized tomography] scan. On 1/11/23 a Fall Committee note indicated that resident 146 was found with two gashes . above and below right eye. Bruising noted on right eye and chin. Resident had rotator cuff injury to left arm with sling in place . Right eye laceration was treated and closed with glue. On 1/30/23 at 10:09 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN1 stated that the day of Resident 146's fall on 1/8/23, resident 146 had received an x-ray. LPN 1 stated after the x-ray tech finished working with Resident 146, the x-ray tech left Resident 146's bed in the high position and did not replace the floor mat, which was moved so the x-ray could be taken. On 1/30/23 at 12:07 PM, LPN 2 was interviewed. LPN 2 stated she was the staff member that found resident 146 after the fall on 1/8/23. LPN 2 stated that the bed was in the high position, that the bed mat was not in place when the fall on this date occurred, and that the bed rails were not in place when this fall occurred. LPN 2 stated that the x-ray tech left the bed in the high position and did not replace the floor mat. An incident report dated 1/13/23 at 11:50 PM stated that, . was found on the floor in her room on floor mat. Bed was in lowest position. Removed air mattress d/t (due to) every time . gets close to the edge of the bed she rolls out with the air mattress. Record review of Resident 146's Minimum Data Set (MDS) Annual assessment dated [DATE] documented that resident 146 has a Brief Interview for Mental Status (BIMS) score of 3, indicating that resident 146 has a severe cognitive impairment. This MDS Annual Assessment also documented that resident 146 requires assistance to complete Activities of Daily Living (ADLs). On 01/25/2023 at 10:22 AM, Resident 146 was observed laying in her bed. The bed was placed low to the ground and there was a fall mat next to her bed. POTENTIAL FOR HARM 2 . Resident 41 was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, insomnia, and dementia. Resident 41's medical record was reviewed on 1/23/23. An incident report dated 12/29/2022 at 6:55 AM stated, CNAs (certified nursing assistants) were doing their rounds around 0430 (4:30 AM) and walked into Res (resident) room and found her on the floor. Her head was on the opposite side of the headboard laying on her blanket. Her legs were under her bed and she had a small skin tear and bruise on her right upper front hip area. She was awake and responding but was having a hard time breathing. She was put back on her bed. Resident unable to give Description. Her vitals were taken and we started neuro checks. Her BP (blood pressure) was 134/100, P (pulse) 89, O2 (oxygen) 77, RR (respiratory rate) 20. She seemed to have some trouble breathing so I started her on 2L (liters) of oxygen and tested her or [sic] covid. Her O2 (oxygen) went up to 88 and her covid test came back positive. Her pupils were reactive and she has some weakness on her left arm compared to her right arm. She was reacting to her name and was Ox3. Neuro checks are being done according to the times on sheet. A tiger text was sent to provider [Medical Director] and DON (Director of Nursing). An incident report dated 1/20/23 at 4:05 PM stated, The CNA reported that resident was trying to fight with brief change and trying to hit/kick him and then fell out of bed and hit her head on the floor. The bleeding from corner of R (right) eye laceration. The nursing staff helped her back in bed, assessed, the bleed from corner of R (right) eye laceration. The laceration site seen by wound nurse and ADON (Assistant Director of Nursing) , new order to send her out to ER (Emergency Room). Resident has sent to ER. The care plan, orders, and Minimum Data Set (MDS) Assessments for resident 41 were reviewed. Resident 41 had orders for a fall mat to be next to her bed and for her bed to be in the low position since 9/15/22. Resident 41's Quarterly MDS dated [DATE] documented that Resident 41 has Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was unable to complete the interview. The MDS also documented that Resident 41 required assistance to complete Activities of Daily Living (ADLs). On 1/25/23 at 10:24 AM, Resident 41's room was observed. There was no fall mat next to her bed, and the bed was not in a low position. On 1/25/23 at 1:44 PM, CNA 1 was interviewed. CNA1 stated that Resident 41 fell down sometimes, so there should be cushioning on the floor next to Resident 41's bed and the bed should be in a low position. 3. On 1/30/23 at 11:30 PM, an observation was made of the Wound Nurse (WN) and CNA 2. The WN and CNA 2 were observed to enter the room of resident 27. Resident 27 was lying in his bed, the WN raised the resident's bed to approximately waist height and both the WN and CNA 2 pulled resident 27 toward the edge of the bed. The WN and CNA 2 then walked out into the hallway to obtain hand sanitizer. No side rails were observed to be pulled up on the bed. The WN and CNA 2 returned to the bedside of resident 27, gloves were donned. The WN pulled back the soiled brief, blood was observed on the brief. No dressing was observed on the wound. The WN cleaned the wound on resident 27 with dry gauze. Resident 27 said ouch as the wound was cleaned. The wound area had different shades or red, and dark red, neither area blanched when pressed on by the WN. The WN stated, We debrided last week, that's why it hurts. No pain alleviation offered to resident 27. The WN again left the bedside to go to the hallway to obtain hand sanitizer. CNA 2 was standing at the foot of the bed with his back to the resident. While the WN was in the hallway, the soiled brief was observed to return to the original position and touch the cleaned wound. The WN donned gloves and returned to the bedside and repositioned resident 27 using the draw sheet on the bed. Gloves were not observed to be changed. The WN applied ointment to a gloved finger then to the wound. The WN and CNA 2 were then called away to the doorway, the soiled brief again returned to its original position and touched the wound. The WN returned to the bedside, pulled the brief away from the wound and a new dressing was applied to the wound. The WN then put the soiled brief back in place over the new dressing on resident 27. At that time, both the WN and CNA 2 were observed to have left the room to obtain hand sanitizer, resident 27 was still observed to be close to the edge of the elevated bed with no side rails in position. Both staff then returned to reposition resident 27.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 298 was admitted on [DATE] with diagnoses which included femur fracture, history of falling, chronic respiratory failure with hypoxia, cognitive communication deficit, dysphagia, need for assistance with personal care, and chronic obstructive pulmonary disease (COPD). On 1/23/23 at 12:00 PM, an interview was conducted with resident 298's family member (FM). The FM stated the resident was admitted on [DATE] at 8:00 AM and went almost an entire day without his pain being controlled. The FM stated the facility would not give resident 298 any pain medication because they didn't have an order (air quotes used when the FM said this). The FM stated on her arrival she demanded the nurse get resident 298 something for pain and the nurse went straight to the facility supply and got resident 298 a pain medication. The FM stated it did help resident 298 but he wouldn't have gotten anything if she had not come in. On 1/24/23, resident 298's medical record was reviewed. Resident 298 was admitted to the facility in the morning on 1/21/23, the first vital sign check was documented at 9:53 AM. A physician order dated 1/20/23 revealed an order for Tramadol 50 mg give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. A physician order dated 1/21/23 revealed an order for Percocet tablet 5-325 milligrams (mg) give 1 tablet by mouth every 4 hours as needed for pain. The Medication Treatment Record (MAR) for January 2023 revealed, at 1:56 PM resident 298 had pain at a level 5 on a 0-10 pain scale with 0 being no pain and 10 being immense pain. A Non-pharmalogical Intervention (NPI) was documented at 1:56 PM as, speak to/approach in a calm manner. No pain medication was documented as administered to resident 298. No documentation was found in the medical record of Tramadol being administered to resident 298 on 1/21/23. On 1/21/23 at 9:59 PM, the MAR documented resident 298 continued to complain of pain at a level 5 on the 0-10 pain scale and was administered Percocet 5mg. Note: This was 8 hours after resident 298 complained about pain. The pain medication was administered by the oncoming night shift nurse not the admitting day shift nurse. On 1/30/23 at 1:50 PM, an interview was conducted with Licensed Practical Nurse (LPN) 9. LPN 9 stated she was the nurse who admitted resident 298 to the facility on 1/21/23. LPN 9 stated the resident, and his family were upset because all she could give him was Tramadol for pain because the provider had already been into the facility to see the residents for the day, so the resident's orders didn't get sent to the pharmacy until the next day. LPN 9 stated she could have gotten the narcotic pain medication out of the house supply with a verbal order from the provider. LPN 9 stated that she probably should have done that sooner and that the family was upset she didn't give the resident anything for his pain except Tramadol. LPN 9 stated the resident had been restless and upset, but he then settled down after his oxygen was put on and his pain medication was given. Note: There is no documented administration of Tramadol to resident 298 in the January MAR. The first dose was documented as given at 10:37 AM on 1/22/23 by LPN 9. On 1/30/23 at 3:02 PM, an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) 1. The ADON 1 stated the admitting nurse should get the resident settled in the room, assess their needs, if the resident is in pain the nurse should check the orders and provide the pain medication that is ordered. The ADON 1 stated the facility does have a supply of medications, including narcotic pain medication, in a locked machine. If the resident is in need of a pain medication the nurses can get one from the machine while they wait for the resident's medications to arrive from the pharmacy. The ADON 1 stated a resident should not sit in pain while staff wait for a medication to come from the pharmacy if it is available in the facility. Based on interview, observation and record review, the facility did not ensure that pain management was provided to 2 of out 54 residents. Specifically, residents complained of pain but were not provided with pain relief medication in a timely manner. These findings resulted in harm for both residents. Resident identifiers: 22 and 298. Findings include: HARM 1. Resident 22 was admitted to the facility on [DATE] with diagnoses that included degenerative disc disease; dementia; schizoaffective disorder, bipolar type; post-traumatic stress disorder; scoliosis; and hypertension. On 1/23/23 resident 22's medical record was reviewed. A care plan for resident 22 was developed on 3/9/20 with a focus area of Has acute and chronic pain r/t (related to) Chronic Physical Disability, pain in lower back, hip and knees. Goals included: Will voice a level of comfort of (sic) through the review date, Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date, and Will not have an interruption in normal activities due to pain through the review date. Interventions included: Able to call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increases or alleviates pain; anticipate need for pain relief and respond immediately to any complaint of pain; engage in daily recreation activities for distraction to manage pain; monitor/record/report any signs and symptoms of non-verbal pain; and monitor/report to nurse if resident complains of pain or has requests for pain treatment. On 10/4/22, the Director of Nursing (DON) completed a quarterly Pain Management Review for resident 22. Despite resident 22's care plan indicating that resident 22 was able to describe his pain, the DON documented that resident 22 was unable to be interviewed. The DON also indicated that no observations were made of resident 22 in pain, but in contrast, that resident 22 was receiving oxycodone as needed for pain. On 1/4/23 a quarterly Pain Management Review was completed by facility staff for resident 22. The pain review indicated that resident 22 was interviewed that day. The review also indicated that resident 22 was receiving oxycodone for pain, and that at the time of the interview, resident 22 was experiencing pain at a level of 6 out of 10. The pain review indicated that resident 22 would like to experience no pain. The pain review also indicated that resident 22 had experienced pain in the last 5 days on a daily basis or several times a day. The review specified that the pain was located in resident 22's right knee and was especially bad in the late evening. At that time, resident 22 described the pain as stabbing, and that it affected his sleep. Resident 22 also indicated that physical activity made the pain worse, but rest and repositioning relieved the pain. Staff documented on the pain review that resident 22 could be observed to have difficulty sleeping and/or make facial expressions such as grimacing when he was experiencing pain. The goal was to Encourage the resident to verbalize his needs, and pain level before medication and document effectiveness of medication. The facility Provider Notifications binder at the nurse's station in the 100 hall was reviewed. The binder indicated that on 1/23/23 resident 22 was requesting time of scheduled oxy (oxycodone) to be changed from 1600 (4:00 PM) to 1400 (2:00 PM). The facility Provider Orders binder at the nurses station in the 100 hall was reviewed. The binder indicated that on 1/23/23 an order was written to increase resident 22's oxycodone to every 4 hours as needed. The order was signed by the Nurse Practitioner (NP). On 1/24/23 at approximately 9:30 AM, resident 22 was observed to approach the facility NP at the nurse's station. Resident 22 was observed to tell the NP that he was experiencing an increased amount of pain. The NP responded to resident 22 by stating that she was aware of his request for an increased dosage of his pain medication, and had approved it, so the resident should start to experience pain relief soon. On 1/24/23, the facility Nurse Practitioner (NP) entered an encounter note in resident 22's medical record. The encounter note indicated that Patient is seen today with complaint of pain. He states this pain is mostly in his knees, though he has pain to his back as well. He states he has been taking oxycodone every 6 hours but will have to take Tylenol in between because it does not carry through long enough. He states mostly at night it is very bothersome for him and makes for a long rough night. He states that he would like his oxycodone increased to every 4 hours. He also has a scheduled dose at 4:00 in the afternoon, that he would like changed to earlier in the afternoon. The NP documented resident 22's pain level at a 6. The NP documented that resident 22 had a diagnosis of Osteoarthritis involving multiple joints on both sides of body and to Increase Oxycodone to every 4 hours as needed and Change scheduled oxycodone to 1400 (2:00 PM) from 1600 (4:00 PM). On 1/25/23 at 8:45 AM, an observation was made of resident 22. Resident 22 walked down the hallway and stopped at the nurse's station. Licensed Practical Nurse (LPN) 6 was observed to be in the nurses station standing at the medication cart. Resident 22 approached LPN 6 and stated that his knee hurt. LPN 6 did not look up from the medication cart or acknowledge resident 22. LPN 6 then stated, Well, you will just have to wait a minute I'm busy. Resident 22 nodded and went over to a chair across from the nurse's station and sat down. LPN 6 was not observed to administer any pain medication to resident 22 during the medication pass observation. On 1/25/23 at 10:50 AM, resident 22 was approached by a staff member and invited to participate in a facility activity. Resident 22 responded by saying that he could not go to the activity because his knees hurt too much. Resident 22 also stated that he thought he could not have more medications until 3:00 PM, and that was too far away. On 1/25/23 at 11:10 AM, resident 22 was observed to approach LPN 6 at the nurse's station, and ask for a pain pill, stating that his knee is really hurting. Resident 22 was observed to be bending over at the waist and rubbing his right knee while grimacing. LPN 6 stated, Ya, I know I'm sorry. LPN 6 did not make any other comments to the resident, and turned away from the resident while the resident was standing at the nursing station. On 1/25/23 at 11:12 AM, LPN 6 approached resident 22 and handed him a cup of water, and a cup containing a pill. LPN 6 immediately turned around and walked back to her medication cart without observing if resident 22 swallowed the pill. In addition, LPN 6 did not assess resident 22's pain level. On 1/25/23 at 11:35 AM, resident 22's Controlled Drug Record was reviewed. The record did not have any oxycodone listed as having been signed out by LPN 6 that day. Resident 22's Medication Administration Record (MAR) did not indicate any as needed pain medications given on 1/25/22 at 11:12 AM by LPN 6. On 1/25/23 at 12:14 PM, resident 22 was observed to ask LPN 6 if she could put some cream on his knee because it was still hurting. LPN 6 responded by asking if the pain medications had helped, and resident 22 stated Not totally. On 1/25/23 at 12:45 PM, an interview was conducted with resident 22. Resident 22 stated that not last night but the night before, indicating the evening of 1/23/23, his pain had increased to a 9 out of 10. Resident 22 stated that at that time facility staff put ice and aspercreme on his knee and had given him some oxycodone. Resident 22 stated that after those interventions he was able to get another 2 hours of sleep. On 1/25/23 at 2:20 PM, an interview was conducted with LPN 6. LPN 2 stated that she had given oxycodone to resident 22 at 11:11 AM and had documented it. When asked about the Provider Notification and Provider Orders binders, LPN 6 stated that one binder was to let the providers know of any concerns, and the other binder was for providers to record their responses. LPN 6 stated that she checked the binder at the beginning of each shift, but that there really isn't a process in place yet. LPN 6 reviewed the binder and confirmed that resident 22 was to have his oxycodone increased as of 1/23/23. A nurses note dated 1/26/23 indicated that resident 22's Oxycodone 5mg increased to q4 (every four hours) prn (as needed) from q6 (every six hours) prn per NP on 1/25/23. New increased dose started today, resident aware of new changes. The entry was made by Assistant Director of Nursing (ADON) 2, not LPN 6 even though LPN 6 was made aware on 1/25/23. Resident 22's January 2023 MAR was reviewed. On 1/25/23, resident 22 did not receive his 4:00 PM scheduled dose of oxycodone. The MAR also indicated that resident 22's increased oxycodone orders did not go into effect until the morning of 1/26/23. On 1/30/23 at 11:02 AM, a follow up interview was conducted with resident 22. Resident 22 was asked about his pain management. Resident 22 produced a notepaper and stated that he had spoken with the NP on 1/23/23, and that the NP agreed to increase his pain medications. Resident 22 stated that it took time for the orders to get processed so he was without the increased dose for a day or longer. Resident 22 also stated that the oxycodone only covered his pain for 4 hours, and before his pain medication dose was increased, he was using lidocaine ointment to help get him through the remaining two hours before he could have more oxycodone. Resident 22 stated that by the end of the 4 hours his pain level was a 4 to 5, but at the end of 6 hours without pain medication his pain level increased to a 6. Resident 22 stated that he had a diagnosis of scoliosis, so it put his hip out, causing pain. Resident 22 stated that the majority of his pain was from his right knee which he injured in a fall. On 1/30/23 at 11:25 AM, an interview was conducted with the NP. The NP stated that she spoke with resident 22 two weeks ago at which time resident 22 talked about the pain with me. The NP stated that on 1/23/23 she had spoken with resident 22 about his pain again, at which time she approved the increase in pain medication. The NP stated that she wrote the order for the increased pain medication in the binder at the nurse's station. The NP stated that whenever she wrote an order in the binder, she always verbally informed the nurse on duty about the new order as well. On 1/30/23 at 11:35 AM, an interview was conducted with the Medical Director (MD). The MD stated that approximately three weeks ago, he and the NP had started a new process of writing down the new orders in a binder at the nurses station. The MD stated that when there was a verbal order given, the MD or NP would tell the nurse on duty, and write it in the binder so there was a record of the verbal order. The MD stated that he expected nurses to put the verbal order into effect ASAP, at most an hour.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation the facility did not ensure that 7 of 54 sample residents were free of neglect. Specifically, residents were not assisted with activities of daily living, had untreated pain, experienced weight loss, experienced falls with injuries, and obtained wounds. The findings for all the residents listed in this deficiency were cited at a harm level. Resident identifiers: 22, 27, 33, 47, 146, 244, and 298. Findings include: HARM ASSISTANCE WITH TOILETING 1. Resident 27 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, Parkinson's disease, neurocognitive disorder with Lewy Bodies, neuropathy, and insomnia. Resident 27's medical record was reviewed on 1/23/23. Resident 27's quarterly Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The MDS indicated that resident 27 was severely cognitively impaired. The MDS indicated that resident 27 required extensive assistance of two people for bed mobility, transferring, dressing, and toilet use. The MDS indicated that resident 27 required extensive assistance of one person for personal hygiene and bathing. The MDS further indicated that resident 27 was unable to move on and off the toilet without staff assistance. The MDS also indicated that resident 27 was always incontinent of bladder, and frequently incontinent of bowel. And the MDS also indicated that resident 27 was at risk for pressure sores, and currently had Moisture Associated Skin Damage (MASD). On 2/8/22 facility staff developed a care plan for resident 27 indicating that the resident had an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Immobility secondary to Parkinson's disease, impaired cognition secondary to Dementia with Lewy bodies . The goal listed was to safely perform bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Interventions on the care plan included Requires Extensive assistance staff participation to use toilet, Requires Extensive assistance staff participation with transfer, and Requires Extensive Assistance staff participation to reposition and turn in bed. On 11/11/22 facility staff developed a care plan for resident 27 indicating that he had MASD to his sacrum related to incontinence. The care plan goal indicated that resident 27 Will be free from MASD through the review date. Interventions included encourage good nutrition and hydration in order to promote healthier skin, identify potential causative factors and eliminate/resolve, when possible, reposition frequently, treatment as ordered, and wound nurse to follow. Resident 27's medical record indicated that from 1/1/23 through 1/29/23, resident 27 required extensive assistance or was totally dependent on staff for bed mobility 69 of 79 opportunities. On 10/20/22 a weekly skin evaluation indicated that resident 27 has reddened Non blanchable area to his LT (left) buttock. Area was cleaned and barrier cream applied. [Note: No documentation could be found to indicate that the wound nurse had observed the wound until 11/11/22, approximately 22 days later.] On 10/29/22 a nurses note documented, Coccyx with open area. Wound care tech came and treated wound. Cleaned wound Anasept applied then dressing. Wound care nurse was notified. [Note: The first wound note was not entered until 11/11/22, approximately 14 days later.] On 11/10/22 a nurses note documented, Pt (patient) continues to area (sic) to buttocks that is no (sic) blanchable. I had informed the MD in the past about this area. We have applied barrier cream and bridged him while in bed. I have informed the wound CNA (Certified Nursing Assistant) about area. On 11/11/22 a nurses note documented, Wound care team assessed sacrum, 2.3 [centimeter (cm)]x (by)3.1xUTD (unable to determine) open area with redness in surrounding tissue wound bed is 40 slough, 30 granular, 30 macerated. entire area is blanching. On 11/16/22 resident 27 was assessed by a Physician Assistant-Certified (PA-C). The PA-C documented that the resident had MASD on his sacrum that had been present longer than one week. The size of the wound was documented as 2.3 cmx3.1 cm x UTD, with 90 percent granulation and 10 percent slough. The PA-C documented that the Tissue does blanch. The PA-C indicated that with each brief change, staff were to remove resident 27's dressing, cleanse the wound, apply skin prep to periwound, apply Medihoney to wound bed, and cover with Bandage. On 11/17/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that resident 27 had MASD to his sacrum that was 2.3x3.1xUTD . Patient has new MASD that is open, initial visit with wound provider this week, debrided with a curette to remove slough and macerated edges. Patient has barriers in wound healing of cognitive impairment and incontinence. MD (medical doctor) and family notified. On 11/18/22 a nurses note documented, Wound note MASD to sacrum wound nurse to call family. On 11/23/22, a Skin Ulcer Non-Pressure Weekly assessment was initiated for resident 27 but was left blank. On 11/23/22, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound had increased in size and measured 2.5x3.4xUTD. On 11/28/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that the wound had increased in size and measured 2.5x3.4xUTD. On 12/5/22, resident 27 was assessed by a PA-C. The PA-C documented that Selective debridement due to slough today; 50 [percent] granular tissue with granular buds noted post debridement. Continue with current treatment. Pt is soiled today. On 12/12/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that the wound was unchanged in size from 11/28/22. On 12/14/22, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound measured 2.4x3.6xUTD. The periwound was described as Macerated. The PA-C documented that Sizes slightly larger after last week's debridement with increased granular tissue. Continue treatment. On 12/21/22, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's sacrum had increased slough, so selective debridement was completed. On 12/28/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that resident 27's wound measured 2.1x2.5xUTD. On 1/1/23 a nurses note documented, Resident has ongoing pressure wound to coccyx, difficult for resident to turn on side. Has pressure reducing mattress in place. On 1/4/23, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound measured 1x2.1x0.3. On 1/11/23, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound measured 1.5x2.3x0.3, which indicated the wound had increased in size. On 1/27/23, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that the wound had not changed in size since 1/11/23. No documentation was located to indicate what days and times, if any, resident 27 refused to be repositioned or have his brief changed. On 1/30/23 at 11:30 PM, an observation was made of the Wound Nurse (WN) and CNA 2. The WN and CNA 2 were observed to enter the room of resident 27. Resident 27 was lying in his bed. The WN raised the resident's bed to approximately waist height and both the WN and CNA 2 pulled resident 27 toward the edge of the bed. The WN and CNA 2 then walked out into the hallway to obtain hand sanitizer. No side rails were observed to be pulled up on the bed, as resident 27 was lying on his right side, with his back near the edge of the bed, unattended by staff. The WN and CNA 2 returned to the bedside of resident 27 and donned gloves. The WN pulled back the soiled brief, and blood was observed on the brief. No dressing was observed on the wound. The WN cleaned the wound on resident 27 with dry gauze. Resident 27 said ouch as the wound was cleaned. The wound area had different shades of red, and dark red, neither area blanched when pressed on by the WN. The WN stated, We debrided last week, that's why it hurts. No pain alleviation was offered to resident 27. The WN again left the bedside to go to the hallway to obtain hand sanitizer. CNA 2 was standing at the foot of the bed with his back to the resident. While the WN was in the hallway, the soiled brief was observed to return to the original position and touch the cleaned wound. The WN donned gloves and returned to the bedside and repositioned resident 27 using the draw sheet on the bed. Her gloves were not observed to be changed. The WN applied ointment to a gloved finger then to the wound. The WN and CNA 2 were then called away to the doorway, the soiled brief again returned to its original position and touched the wound. The WN returned to the bedside, pulled the brief away from the wound and a new dressing was applied to the wound. The WN then put the soiled brief back in place over the new dressing on resident 27. At that time, both the WN and CNA 2 were observed to have left the room to obtain hand sanitizer, resident 27 was still observed to be close to the edge of the elevated bed with no side rails in position. Both staff then returned to reposition resident 27. On 1/30/23 at 11:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 8. When asked about resident 27, LPN 8 stated that staff were instructed to help the resident turn and keep him off his bum. LPN 8 stated that resident 27 did not get out of bed or attempt to get out of bed during the nighttime hours. LPN 8 stated that resident 27's sacrum wound was old and that it was caused by staff not repositioning the resident or changing his incontinence briefs timely. LPN 8 stated that in the recent past, there would only be one CNA assigned to the memory care unit, which was not enough to ensure the safety and good care of the residents. ASSISTANCE WITH EATING 2. Resident 244 was admitted to the facility on [DATE] with diagnoses that included but not limited to gastro esophageal reflux disease, muscle weakness, major depressive disorder, anxiety disorder, and insomnia. Resident 244's medical record was reviewed on 1/24/23. An annual Minimum Data Set (MDS) assessment dated [DATE], documented that resident 244 required supervision assistance with one person. In addition, a quarterly MDS assessment dated [DATE] documented that resident 244 had a Brief Interview for Mental Status (BIMS) score of 15. A Plan of Care problem with an effective date of 1/4/17 documented that resident 244 required extensive assist with bed mobility, transfers, . eating, toilet use and personal hygiene. Another care area identified with an effective date of 1/24/17 documented that resident 244 was at nutritional risk as evidence by periods of decreased oral intake. An intervention implemented on 1/1/18, documented that resident 244 would have weekly weights x 30 days and monthly if stable and to promptly identify signs and symptoms of weight loss and dehydration; interventions initiated timely daily. [Note: no weekly weights were done.] Registered Dietician Nutritional Risk Review dated 12/22/22 documented that resident 244 had an 8% (percent) weight loss since 11/2/22. A nurse practitioner/ physician assistant progress note dated 8/25/22 documented that resident 244 had some noted weight loss recently due to food preferences. A nurse practitioner/ physician assistant progress note dated 12/27/22 documented that resident 244's sister expressed concerns on 12/7/22 about resident 244's difficulty eating and stated it took resident 244 a long time to eat the food that he had so far. A new patient encounter progress note dated 1/3/23 documented that resident 244 had reportedly been losing weight. On November 2 he weighed 187 pounds, today he weighs 168 which is a 10% weight loss. He states his appetite has not been very good as he just has not felt well. He remains at risk for significant weight loss and malnutrition. The exact meal percentage consumption for the last 30 days documented that resident 244 had consumed 50 % or less of his meals for 46 out of 72 documented encounters. The snack consumption for the last 30 days documented that resident 244 accepted a snack 3 times out of the 24 instances documented. On 1/23/23 at 10:25 AM, resident 244 was observed sitting up in his bed with his eyes closed. A breakfast meal tray was observed on a bedside table in front of resident 244. Most of the food on the breakfast tray appeared to be untouched except, for the cereal. On 1/25/23 at 12:05 PM, resident 244 was observed to have his eyes closed when his lunch tray was dropped off. The lunch tray was observed on a bedside table located to the right of resident 244. Resident 244 eye's continued to appear closed until 12:16 PM. On 1/25/23 at 1:47 PM, resident 244 was observed to have his eyes closed and lunch tray at bedside remained untouched. On 1/26/23 at 10:00 AM, resident 244 was observed to have his eyes closed and had a napkin placed across his chest with a handful of cheerios scattered across the napkin. A breakfast meal tray was observed on a bedside table in front of the resident. The breakfast meal tray had a piece of toast with jelly, a cut up sunny side up egg and a bowel of cheerios. The cheerios were the only item of food that was touched by the resident. On 1/26/23 at 12:10 PM, resident 244 was observed to be sitting up in bed and staring at his food with shaking hands. A lunch tray compromised of meat and rice was observed on a bedside table located in front of resident 244. Resident 244 continued to stare at his food for 17 minutes before he picked up his cup of milk with a shaky hand. Resident 244 was observed to bring the cup of milk to his mouth without spilling but began to cough when he drank the milk. Resident 244 was then observed to spill the remainder of his milk as he tried to put the cup back on his bedside table. A follow up interview was conducted with resident 244. Resident 244 stated he did not like his food, and he did not plan to eat it. Resident 244 stated the only thing he liked was the milk and that he was not hungry. On 1/26/23 at 1:17 PM, resident 244 was observed to have his eyes closed and his lunch tray appeared to be untouched expected for the milk he drank. On 1/30/23 at 12:07 PM, resident 244's sister was observed to feed resident 244 homemade soup. A follow up interview was conducted with resident 244. Resident 244 stated he needed help feeding himself. Resident 244 stated that staff took his meal trays away and had not offered him any meal substitutions when he did not like the food. On 1/26/23 at 11:15 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated the resident 244 was an extensive two person assist and needed to be pulled up in bed for every meal. CNA 3 stated that resident 244 ate in his room and that he was capable of feeding himself. CNA 3 stated that the only help resident 244 required with meals was to have his tray set up for him. CNA 3 stated they were unsure the percentage of his meals that he ate. On 1/25/23 at 12:34 PM, an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated that resident 244 was able to feed himself and only required setup assist with his tray. The MDSC stated that resident 244 didn't always eat all his food because he didn't like what he was served. The MDSC stated that resident 244 got a boost with all his meals as a supplement. On 1/26/23 at 10:46 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 244 ate about 25% of his breakfast today. CNA 2 stated resident 244 didn't eat very much of his meals. CNA 2 stated that resident 244 was capable of using silverware and was able to feed himself and did not require any help that he was aware of. On 1/26/23 at 12:35 PM, an interview was conducted with the Occupational Therapist (OT). The OT stated they had not worked with resident 244 since October. The OT was asked if resident 244 was able to feed himself with his shaky hands and the OT responded that they were unsure how much help resident 244 needed with meals. The OT stated they evaluated and worked with residents that needed more assistance on ADLs. The OT stated they were not working with resident 244 since he didn't need help with any ADLs that he was aware of. On 1/30/23 at 11:11 AM, an interview was conducted with Licensed Practical Nurse (LPN)1. LPN 1 stated that resident 244 was able to feed himself and was able to reach for his own waters. LPN 1 stated that every once in a while, resident 244 did not each much but stated that he always ate his cereal. On 01/30/23 at 12:21 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that resident 244 was a set up assistance for meals. The CNAC stated they made sure to sit him up in bed and during brief changes. The CNAC stated she handed resident 244 his chocolate milk with meals and stated that resident 244 did not have problems grabbing thing with his hands. The CNAC stated there were times where he did not eat his food because he did not like what was serve to him. The CNAC stated that resident 244 verbalized when he did not like his meal. The CNAC stated they have asked resident 244 if he needed help with meals but stated that resident 244 has refused the help. The CNAC stated they thought it was weird that resident 244's sister was feeding him lunch today because resident 244 was able to feed himself and did not that much help with meals. On 1/30/23 at 3:56 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that supervision assist meant that a staff member had to help and encourage the resident to eat during meals. The DON stated if the resident's MDS documented him as a supervision assist, she expected staff to be at bedside during mealtimes to help feed him. The DON that when a resident has a 10% weight loss, they were triggered for weight loss and put on weekly weights, as well as reviewed in the weekly Nutrition at Risk meetings. PAIN MANAGEMENT 3. Resident 22 was admitted to the facility on [DATE] with diagnoses that included degenerative disc disease; dementia; schizoaffective disorder, bipolar type; post-traumatic stress disorder; scoliosis; and hypertension. On 1/23/23 resident 22's medical record was reviewed. A care plan for resident 22 was developed on 3/9/20 with a focus area of Has acute and chronic pain r/t (related to) Chronic Physical Disability, pain in lower back, hip and knees. Goals included: Will voice a level of comfort of (sic) through the review date, Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date, and Will not have an interruption in normal activities due to pain through the review date. Interventions included: Able to call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increases or alleviates pain; anticipate need for pain relief and respond immediately to any complaint of pain; engage in daily recreation activities for distraction to manage pain; monitor/record/report any signs and symptoms of non-verbal pain; and monitor/report to nurse if resident complains of pain or has requests for pain treatment. On 10/4/22, the Director of Nursing (DON) completed a quarterly Pain Management Review for resident 22. Despite resident 22's care plan indicating that resident 22 was able to describe his pain, the DON documented that resident 22 was unable to be interviewed. The DON also indicated that no observations were made of resident 22 in pain, but in contrast, that resident 22 was receiving oxycodone as needed for pain. On 1/4/23 a quarterly Pain Management Review was completed by facility staff for resident 22. The pain review indicated that resident 22 was interviewed that day. The review also indicated that resident 22 was receiving oxycodone for pain, and that at the time of the interview, resident 22 was experiencing pain at a level of 6 out of 10. The pain review indicated that resident 22 would like to experience no pain. The pain review also indicated that resident 22 had experienced pain in the last 5 days on a daily basis or several times a day. The review specified that the pain was located in resident 22's right knee and was especially bad in the late evening. At that time, resident 22 described the pain as stabbing, and that it affected his sleep. Resident 22 also indicated that physical activity made the pain worse, but rest and repositioning relieved the pain. Staff documented on the pain review that resident 22 could be observed to have difficulty sleeping and/or make facial expressions such as grimacing when he was experiencing pain. The goal was to Encourage the resident to verbalize his needs, and pain level before medication and document effectiveness of medication. The facility Provider Notifications binder at the nurse's station in the 100 hall was reviewed. The binder indicated that on 1/23/23 resident 22 was requesting time of scheduled oxy (oxycodone) to be changed from 1600 (4:00 PM) to 1400 (2:00 PM). The facility Provider Orders binder at the nurses station in the 100 hall was reviewed. The binder indicated that on 1/23/23 an order was written to increase resident 22's oxycodone to every 4 hours as needed. The order was signed by the Nurse Practitioner (NP). On 1/24/23 at approximately 9:30 AM, resident 22 was observed to approach the facility NP at the nurse's station. Resident 22 was observed to tell the NP that he was experiencing an increased amount of pain. The NP responded to resident 22 by stating that she was aware of his request for an increased dosage of his pain medication, and had approved it, so the resident should start to experience pain relief soon. On 1/24/23, the facility Nurse Practitioner (NP) entered an encounter note in resident 22's medical record. The encounter note indicated that Patient is seen today with complaint of pain. He states this pain is mostly in his knees, though he has pain to his back as well. He states he has been taking oxycodone every 6 hours but will have to take Tylenol in between because it does not carry through long enough. He states mostly at night it is very bothersome for him and makes for a long rough night. He states that he would like his oxycodone increased to every 4 hours. He also has a scheduled dose at 4:00 in the afternoon, that he would like changed to earlier in the afternoon. The NP documented resident 22's pain level at a 6. The NP documented that resident 22 had a diagnosis of Osteoarthritis involving multiple joints on both sides of body and to Increase Oxycodone to every 4 hours as needed and Change scheduled oxycodone to 1400 (2:00 PM) from 1600 (4:00 PM). On 1/25/23 at 8:45 AM, an observation was made of resident 22. Resident 22 walked down the hallway and stopped at the nurse's station. Licensed Practical Nurse (LPN) 6 was observed to be in the nurses station standing at the medication cart. Resident 22 approached LPN 6 and stated that his knee hurt. LPN 6 did not look up from the medication cart or acknowledge resident 22. LPN 6 then stated, Well, you will just have to wait a minute I'm busy. Resident 22 nodded and went over to a chair across from the nurse's station and sat down. LPN 6 was not observed to administer any pain medication to resident 22 during the medication pass observation. On 1/25/23 at 10:50 AM, resident 22 was approached by a staff member and invited to participate in a facility activity. Resident 22 responded by saying that he could not go to the activity because his knees hurt too much. Resident 22 also stated that he thought he could not have more medications until 3:00 PM, and that was too far away. On 1/25/23 at 11:10 AM, resident 22 was observed to approach LPN 6 at the nurse's station, and ask for a pain pill, stating that his knee is really hurting. Resident 22 was observed to be bending over at the waist and rubbing his right knee while grimacing. LPN 6 stated, Ya, I know I'm sorry. LPN 6 did not make any other comments to the resident, and turned away from the resident while the resident was standing at the nursing station. On 1/25/23 at 11:12 AM, LPN 6 approached resident 22 and handed him a cup of water, and a cup containing a pill. LPN 6 immediately turned around and walked back to her medication cart without observing if resident 22 swallowed the pill. In addition, LPN 6 did not assess resident 22's pain level. On 1/25/23 at 11:35 AM, resident 22's Controlled Drug Record was reviewed. The record did not have any oxycodone listed as having been signed out by LPN 6 that day. Resident 22's Medication Administration Record (MAR) did not indicate any as needed pain medications given on 1/25/22 at 11:12 AM by LPN 6. On 1/25/23 at 12:14 PM, resident 22 was observed to ask LPN 6 if she could put some cream on his knee because it was still hurting. LPN 6 responded by asking if the pain medications had helped, and resident 22 stated Not totally. On 1/25/23 at 12:45 PM, an interview was conducted with resident 22. Resident 22 stated that not last night but the night before, indicating the evening of 1/23/23, his pain had increased to a 9 out of 10. Resident 22 stated that at that time facility staff put ice and aspercreme on his knee and had given him some oxycodone. Resident 22 stated that after those interventions he was able to get another 2 hours of sleep. On 1/25/23 at 2:20 PM, an interview was conducted with LPN 6. LPN 2 stated that she had given oxycodone to resident 22 at 11:11 AM and had documented it. When asked about the Provider Notification and Provider Orders binders, LPN 6 stated that one binder was to let the providers know of any concerns, and the other binder was for providers to record their responses. LPN 6 stated that she checked the binder at the beginning of each shift, but that there really isn't a process in place yet. LPN 6 reviewed the binder and confirmed that resident 22 was to have his oxycodone increased as of 1/23/23. A nurses note dated 1/26/23 indicated that resident 22's Oxycodone 5mg increased to q4 (every four hours) prn (as needed) from q6 (every six hours) prn per NP on 1/25/23. New increased dose started today, resident aware of new changes. The entry was made by Assistant Director of Nursing (ADON) 2, not LPN 6 even though LPN 6 was made aware on 1/25/23. Resident 22's January 2023 MAR was reviewed. On 1/25/23, resident 22 did not receive his 4:00 PM scheduled dose of oxycodone. The MAR also indicated that resident 22's increased oxycodone orders did not go into effect until the morning of 1/26/23. On 1/30/23 at 11:02 AM, a follow up interview was conducted with resident 22. Resident 22 was asked about his pain management. Resident 22 produced a notepaper and stated that he had spoken with the NP on 1/23/23, and that the NP agreed to increase his pain medications. Resident 22 stated that it took time for the orders to get processed so he was without the increased dose for a day or longer. Resident 22 also stated that the oxycodone only covered his pain for 4 hours, and before his pain medication dose was increased, he was using lidocaine ointment to help get him through the remaining two hours before he could have more oxycodone. Resident 22 stated that by the end of the 4 hours his pain level was a 4 to 5, but at the end of 6 hours without pain medication his pain level increased to a 6. Resident 22 stated that he had a diagnosis of scoliosis, so it put his hip out, causing pain. Resident 22 stated that the majority of his pain was from his right knee which he injured in a fall. On 1/30/23 at 11:25 AM, an interview was conducted with the NP. The NP stated that she spoke with resident 22 two weeks ago at which time resident 22 talked about the pain with me. The NP stated that on 1/23/23 she had spoken with resident 22 about his pain again, at which time she approved the increase in pain medication. The NP stated that she wrote the order for the increased pain medication in the binder at the nurse's station. The NP stated that whenever she wrote an order in the binder, she always verbally informed the nurse on duty about the new order as well. On 1/30/23 at 11:35 AM, an interview was conducted with the Medical Director (MD). The MD stated that approximately three weeks ago, he and the NP had started a new process of writing down the new orders in a binder at the nurses station. The MD stated that when there was a verbal order given, the MD or NP would tell the nurse on duty, and write it in the binder so there was a record of the verbal order. The MD stated that he expected nurses to put the verbal order into effect ASAP, at most an hour. 4. Resident 298 was admitted on [DATE] with diagnoses which included femur fracture, history of falling, chronic respiratory failure with hypoxia, cognitive communication deficit, dysphagia, need for assistance with personal care, and chronic obstructive pulmonary disease (COPD). On 1/23/23 at 12:00 PM, an interview was conducted with resident 298's family member (FM). The FM stated the resident was admitted on [DATE] at 8:00 AM and went almost an entire day without his pain being controlled. The FM stated the facility would not give resident 298 any pain medication because they didn't have an order (air quotes used when the FM said this). The FM stated on her arrival she demanded the nurse get resident 298 something for pain and the nurse went straight to the facility supply and got resident 298 a pain medication. The FM stated it did help resident 298 but he wouldn't have gotten anything if she had not come in. On 1/24/23, resident 298's medical record was reviewed. Resident 298 was admitted to the facility in the morning on 1/21/23, the first vital sign check was documented at 9:53 AM. A physician order dated 1/20/23 revealed an order for Tramadol 50 mg give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. A physician order dated 1/21/23 revealed an order for Percocet tablet 5-325 milligrams (mg) give 1 tablet by mouth every 4 hours as needed for pain. The Medication Treatment Record (MAR) for January 2023 revealed, at 1:56 PM resident 298 had pain at a level 5 on a 0-10 pain scale with 0 being no pain and 10 being immense pain. A Non-pharmalogical Intervention (NPI) was documented at 1:56 PM as, speak to/approach in a calm manner. No pain medication was documented as administered to resident 298. No documentation was found in the medical record of Tramadol being administered to resident 298 on 1/21/23. On 1/21/23 at 9:59 PM, the MAR documented resident 298 continued to complain of pain at a level 5 on the 0-10 pain scale and was administered Percocet 5mg. Note: This was 8 hours after resident 298 complained about pain. The pain medication was administered by the oncoming night shift nurse not the admitting day shift nurse. On 1/30/23 at 1:50 PM, an interview was conducted with Licensed Practical Nurse (LPN) 9. LPN 9 stated she

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 244 was admitted to the facility on [DATE] with diagnoses that included gastroesophageal reflux disease, muscle weakness, major depressive disorder, anxiety disorder, and insomnia. Resident 244's medical record was reviewed on 1/24/23. An annual Minimum Data Set (MDS) assessment dated [DATE], documented that resident 244 required supervision assistance by one person to eat his meals. In addition, a quarterly MDS assessment dated [DATE] documented that resident 244 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident 244's care plan was reviewed. The focus area of the care plan that related to Activities of Daily Living (ADLs) for resident 244 dated 1/4/17 documented that resident 244 required extensive assistance for eating. The focus area of the care plan that related to nutrition dated 1/24/17 documented that resident 244 was at nutritional risk as evidenced by periods of decreased oral intake. An intervention implemented on 1/1/18 documented that resident 244 would have weekly weights for 30 days and monthly if stable and to promptly identify signs and symptoms of weight loss and dehydration. The last update to the nutritional risk focus area was on 12/22/22 that indicated the resident will be offered food and fluids and encouraged to eat. The update also indicated that weight loss was expected, but did not indicate the reason. On 7/5/22, staff documented that resident 244 weighed 185 lbs. On 8/2/22, staff documented that resident 244 weighed 179.4 lbs. A nurse practitioner/ physician assistant progress note dated 8/25/22 documented that resident 244 had some noted weight loss recently due to food preferences. No weights were documented for resident 244 between 8/2/22 and 11/2/22. On 11/2/22, staff documented that resident 244 weighed 187 lbs. On 12/6/22, staff documented that resident 244 weighed 173.2 lbs. On 12/6/22, a physician note indicated that a follow up visit was requested due to reported weight loss. Resident has not been eating well. He does report some depression but not as bad as it was before. He does not want to get up out of bed to participate in meals in the dining room as discussed as an option. He is willing to do mirtzapine if any more wt (weight) loss. A Nutrition Interdisciplinary Team Update for resident 244 dated 12/7/22 was reviewed. The Update indicated that resident 244 had lost 7.4 percent of his body weight in one month, and that he was only eating an average of 40 percent of his meals. The Update also indicated that a family member was notified of wt (weight) change via phone call, she is concerned about the loss and would like him to receive additional supplement drinks if possible. She would also like to to (sic) ensure that he is getting the feeding assistance that he needs d/t (due to) his tremors and would like staff to encourage him to come to the dining room for meals. NAR team recommends switch supplement. No indication was made on the Update that resident 244 would received increased assistance with dining, or would be encouraged to eat in the dining room. [Note: This is the only NAR meeting note for resident 244 between 7/1/22 and 1/24/23.] On 12/7/22 a physician note indicated that the physician was visiting with resident 244 and his sister. She is at residents bedside helping him with lunch. She expressed that he has significant difficulty with eating and is taken (sic) a long time to eat the food that he has so far. On 12/13/22, staff documented that resident 244 weighed 172 lbs. A Registered Dietitian Nutritional Risk Review dated 12/22/22 documented that resident 244 had experienced an 8 percent weight loss since 11/2/22, but that a fortified diet and supplements were being given. No other interventions were listed. A nurse practitioner/ physician assistant progress note dated 12/27/22 documented that resident 244 sister expressed concerns on 12/7/22 about resident 244's difficulty eating and stated it took resident 244 a long time to eat the food that he had so far. A new patient encounter progress note dated 1/3/23 documented that resident 244 had reportedly been losing weight. November 2 he weighed 187 pounds, today he weighs 168 which is a 10% weight loss. He states his appetite has not been very good as he just has not felt well. He remains at risk for significant weight loss and malnutrition. On 1/4/22, staff documented that resident 244 weighed 168 lbs. The exact meal percentage consumption for the last 30 days from 12/28/22 through 1/25/23 documented that resident 244 had consumed 50 % or less of his meals for 46 out of 72 documented times. The snack consumption for the last 30 days from 12/2822 through 1/25/23 documented that resident 244 accepted a snack 3 times out of the 24 instances documented. On 1/23/23 at 10:25 AM, Resident 244 was observed sitting up in his bed with his eyes closed. A breakfast meal tray was observed on a bedside table in front of resident 244. Most of the food on the breakfast tray appeared to be untouched except for the cereal. On 1/25/23 at 12:05 PM, Resident 244 was observed to have his eyes closed when his lunch tray was dropped off. The lunch tray was observed on a bedside table located to the right of resident 244. Resident 244 eye's continued to appear closed until 12:16 PM when the observation ended. On 1/25/23 at 1:47 PM, Resident 244 was observed to have his eyes closed and the lunch tray at his bedside appeared untouched. On 1/26/23 at 10:00 AM, Resident 244 was observed to have his eyes closed and had napkin placed across his chest with a handful of cheerios scattered across the napkin. A breakfast meal tray was observed on a bedside table in front of the resident. The breakfast meal tray had a piece of toast with jelly, a cut up sunny side up egg and a bowel of cheerios. The cheerios were the only item of food that appeared to have been eaten by the resident. On 1/26/23 at 12:10 PM, Resident 244 was observed to be sitting up in bed and staring at his food with shaking hands. A lunch tray comprised of meat and rice was observed on a bedside table located in front of resident 244. Resident 244 was observed to stare at his food for 17 minutes before he picked up his cup of milk with a shaky hand. Resident 244 was observed to bring the cup of milk to his mouth without spilling but began to cough when he drank the milk. Resident 244 was then observed to spill the remainder of his milk as he tried to put the cup back on his bedside table. A follow up interview was conducted with resident 244. Resident 244 stated he did not like his food and he did not plan to eat it. Resident 244 stated the only thing he liked was the milk and that he was not hungry. On 1/26/23 at 1:17 PM, Resident 244 was observed to have his eyes closed and his lunch tray appeared to be untouched expected for the milk he drank. On 1/30/23 at 12:07 PM, Resident 244's sister was observed to feed resident 244 homemade soup. A follow up interview was conducted with resident 244. Resident 244 stated he needed help feeding himself. Resident 244 stated that staff took his meal trays away and had not offered him any meal substitutions when he did not like the food. On 1/26/23 at 11:15 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated the resident 244 was an extensive two person assist and needed to be pulled up in bed for every meal. CNA3 stated that resident 244 ate in his room and that he was capable of feeding himself. CNA 3 stated that the only help resident 244 required with meals was to have his tray set up for him. CNA3 stated they were unsure the percentage of meals that resident 244 ate. On 1/25/23 at 12:34 PM, an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated that resident 244 was able to feed himself and only required setup assist with his tray. The MDSC stated that resident 244 didn't always eat all his food because he didn't like what he was served. The MDSC stated that resident 244 got a supplement with his meals. On 1/26/23 at 10:46 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 244 ate about 25% of his breakfast that day. CNA 2 stated resident 244 didn't usually eat very much of his meals. CNA 2 stated that resident 244 was capable of using silverware and was able to feed himself and did not require any help that the CNA was aware of. On 1/26/23 at 12:35 PM, an interview was conducted with the Occupational Therapist (OT). The OT stated they had not worked with resident 244 since October 2022. The OT was asked if resident 244 was able to feed himself with his shaky hands and the OT responded that they were unsure how much help resident 244 needed with meals. The OT stated they evaluated and worked with residents that needed more assistance on activities of daily living (ADLs). The OT stated they were not working with resident 244 since he didn't need help with any ADLs that he was aware of. On 1/30/23 at 11:11 AM, an interview was conducted with Licensed Practical Nurse (LPN)1. LPN 1 stated that resident 244 was able to feed himself and was able to reach for his own waters. LPN 1 stated that every once in a while, resident 244 did not eat much but stated that he always ate his cereal. On 01/30/23 at 12:21 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that resident 244 needed set up assistance for meals. The CNAC stated they made sure to sit him up in bed to eat. The CNAC stated she handed resident 244 his chocolate milk with meals and stated that resident 244 did not have problems grabbing things with his hands. The CNAC stated there were times where resident 244 did not eat his food because he did not like what was served to him. The CNAC stated that resident 244 verbalized when he did not like his meal. The CNAC stated they have asked resident 244 if he needed help with meals but stated that resident 244 had refused the help. The CNAC stated they thought it was weird that resident 244's sister was feeding him lunch today because resident 244 was able to feed himself and did not need that much help with meals. On 1/30/23 at 3:56 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that supervision assist meant that a staff member had to help and encourage the resident to eat during meals. The DON stated if the resident's MDS documented him as a supervision assist, she expected staff to be at bedside during meal times to help feed him. The DON that when a resident has a 10% weight loss, they were triggered for weight loss and put on weekly weights, as well as reviewed in the weekly NAR meetings. Based on interview, observation and record review, the facility did not ensure that 3 of 54 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level for all three residents. Resident identifiers: 33, 47, and 244. Findings include: HARM 1. Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety disorder, osteoporosis, pseudobulbar affect, major depressive disorder, and hypertension. Resident 33's medical record was reviewed on 1/23/23. Resident 33's weights were recorded as follows: a. 7/5/22 - 179.2 pounds (lbs) b. 1/3/23 - 169.4 lbs The weight loss above is a 5.5 percent weight loss in six months. No other weights were recorded for resident 33 between 7/5/22 and 1/3/23. In addition, no weights were recorded after 1/3/23 as of 1/23/23. Review of resident 33's nursing progress notes indicated that no notes had been entered regarding resident 33's weight loss. A Nutrition/Hydration Risk Evaluation dated 1/16/23 indicated that resident 33's weight status was Stable within 3 Months. No indication was made as to how the staff member made this determination. The Evaluation indicated that the resident was at Medium Risk. The Evaluation did not indicate any interventions for resident 33 to maintain or improve his nutritional status. Review of resident 33's assessments indicated that no other nutrition assessments had been completed for resident 33. On 1/30/23 at 3:38 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was part of the Nutrition at Risk (NAR) committee. The DON stated that each week the facility Registered Dietitian (RD) provided the NAR committee members with a list of residents who had experienced weight loss. The DON stated that after a resident experienced weight loss, they were typically reweighed weekly, and evaluated in the weekly NAR meeting until their weight stabilized. The DON stated that residents' weights usually have to be stable for several weeks before the residents would be removed from the list of residents who required weekly weights. The DON confirmed that resident 33 had not been re-weighed or re-evaluated by the NAR committee after experiencing a 10 pound weight loss. The DON did not provide an explanation as to why the resident had not been weighed weekly after the identified weight loss occurred. 2. Resident 47 was admitted on [DATE] with diagnoses that included dementia, diabetes mellitus, hypertension, bipolar disorder, cognitive communication deficit, dysphagia and history of traumatic brain injury. Resident 47's medical record was reviewed on 1/23/23. Resident 47's weights were recorded as follows: a. 6/7/22 - 188 lbs b. 7/5/22 - 186 lbs c. 8/2/22 - 178 lbs d. 8/9/22 - 176 lbs e. 9/6/22 - 174 lbs f. 10/4/22 - 173 lbs g. 11/1/22 - 174 lbs h. 12/6/22 - 169 lbs i. 1/3/22 - 163 lbs No weights were recorded after 1/3/23 for resident 47 as of 1/23/23. The weight loss above is a 12.4 percent weight loss in six months. On 12/6/22, the facility NAR committee recommended to increase resident 47's supplement to 60 milliliters twice daily. On 1/5/22, the facility NAR committee recommended to increase resident 47's supplement to 120 milliliters twice daily. On 1/30/23 at 3:38 PM, an interview was conducted with the facility DON. The DON confirmed that resident 47 had not been re-weighed or re-evaluated by the NAR committee weekly after experiencing a 6 pound weight loss between 12/6/22 and 1/3/22. The DON also confirmed that the NAR committee had not re-evaluated resident 47 after 1/3/23. The DON did not provide an explanation as to why the resident had not been weighed weekly after the identified weight loss had occurred.

Based on interview, record review, and observation, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, residents experienced neglect, did not receive assistance with activities of daily living, experienced pain without timely intervention, developed wounds, experienced falls with injuries, and experienced weight loss without timely intervention. This resulted in seven deficiencies cited at a harm level. In addition, multiple deficiencies that were cited on the previous recertification survey and complaint surveys were re-cited on the current survey. Resident identifiers: 22, 27, 33, 41, 47, 60, 146, 244, 295, 298, and 349. Findings include: 1. Based on interview, record review, and observation the facility did not ensure that 7 of 54 sample residents were free of neglect. Specifically, residents were not assisted with activities of daily living, had untreated pain, experienced weight loss, and experienced falls with injuries. The findings for all the residents listed in this deficiency were cited at a harm level. Resident identifiers: 22, 27, 33, 47, 146, 244, and 298. [Cross refer to F600] 2. Based on interview and record review it was determined, for 1 of 54 sampled residents, that the facility did not provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs). Specifically, a resident did not receive help with feeding assistance and cueing. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. [Cross refer to F676] 3. Based on interview, observation and record review, the facility did not ensure that 4 of 54 sample residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, residents were not assisted with toileting or bathing as needed. This resulted in a finding of harm for one resident. Resident identifiers: 27, 60, 295 and 349. [Cross refer to F677] 4. Based on interview and record review it was determined that the facility did not ensure, for 1 of 54 sample residents, that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices. Specifically, one resident developed a penile wound and did not promptly receive appropriate wound care follow up and no investigation was done on the cause of the wound. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. [Cross refer to F684] 5. Based on observation, interview and record review, for 3 of 54 sampled residents, that the facility did not ensure that the residents' environment remained as free of accident hazards as is possible. Specifically, one resident with a history of falls was left unattended and subsequently fell out of bed, receiving an eye laceration. The deficient practice for this resident was cited at a harm level. In addition, one resident with a history of falls was observed to not have interventions in place, and one resident was left unattended at the side of his bed. Resident identifiers: 27, 41 and 146. [Cross refer to F689] 6. Based on interview, observation and record review, the facility did not ensure that 3 of 54 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level for all three residents. Resident identifiers: 33, 47, and 244. [Cross refer to F692] 7. Based on interview, observation and record review, the facility did not ensure that pain management was provided to 2 of out 54 residents. Specifically, residents complained of pain but were not provided with pain relief medication in a timely manner. These findings resulted in harm for both residents. Resident identifiers: 22 and 298. [Cross refer to F697] 8. On 5/28/21 an annual recertification survey was conducted. Among the deficiencies cited included F550, F584, F600 (at a harm level), F609, F656, F677, F689 (at a harm level), F690 (at a harm level), F695, F697 (at a harm level), F756, and F835. The deficiencies listed were cited again during the current recertification survey. 9. On 6/1/22 a complaint survey was conducted. F880 was cited at that time. F880 was also cited again during the current recertification survey. 10. On 11/3/22 a complaint survey was conducted F550, F677, and F689 were cited. These deficiencies were cited again during the current recertification survey. On 1/30/23 at 3:37 PM, an interview was conducted with the facility Director of Nursing (DON). The DON was asked about the Quality Assurance program, and specifically what had been implemented with regard to brief changes for example. The DON stated that facility CNAs were provided a sheet to document if a resident received a brief change, and how often they should be checked. The DON stated that facility staff should be checking residents' incontinence briefs every couple of hours. When asked how the facility management was ensuring that briefs were being changed timely, the DON stated that facility staff were asking the [CNAs] if they have done their brief changes. On 1/30/23 at 3:17 PM, an interview was conducted with the facility Administrator (ADM). The ADM was asked about the Quality Assurance program, and specifically what had been implemented with regard to brief changes for example. The AM was asked what interventions had been put into place since November 2022 when the facility was cited for F677 after multiple residents were identified as not having their incontinence briefs changed in a timely manner. The ADM stated that they the CNA Coordinator was reviewing the electronic health record documentation to ensure the staff were documenting brief changes. When asked if there was a specific auditing process in place, the ADM stated there was not. When asked if observations were being made by facility management to ensure brief changes were occurring versus being documented, the ADM stated that intervention had not been put into place.

Based on interview, record review, and observation, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies; and regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. Specifically, residents experienced neglect, did not receive assistance with activities of daily living, experienced pain without timely intervention, developed wounds, experienced falls with injuries, and experienced weight loss without timely intervention. This resulted in seven deficiencies cited at a harm level. In addition, multiple deficiencies that were cited on the previous recertification survey and complaint surveys were re-cited on the current survey. Resident identifiers: 22, 27, 33, 41, 47, 60, 146, 244, 295, 298, and 349. Findings include: 1. Based on interview, record review, and observation the facility did not ensure that 7 of 54 sample residents were free of neglect. Specifically, residents were not assisted with activities of daily living, had untreated pain, experienced weight loss, and experienced falls with injuries. The findings for all the residents listed in this deficiency were cited at a harm level. Resident identifiers: 22, 27, 33, 47, 146, 244, and 298. [Cross refer to F600] 2. Based on interview and record review it was determined, for 1 of 54 sampled residents, that the facility did not provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs). Specifically, a resident did not receive help with feeding assistance and cueing. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. [Cross refer to F676] 3. Based on interview, observation and record review, the facility did not ensure that 4 of 54 sample residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, residents were not assisted with toileting or bathing as needed. This resulted in a finding of harm for one resident. Resident identifiers: 27, 60, 295 and 349. [Cross refer to F677] 4. Based on interview and record review it was determined that the facility did not ensure, for 1 of 54 sample residents, that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices. Specifically, one resident developed a penile wound and did not promptly receive appropriate wound care follow up and no investigation was done on the cause of the wound. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. [Cross refer to F684] 5. Based on observation, interview and record review, for 3 of 54 sampled residents, that the facility did not ensure that the residents' environment remained as free of accident hazards as is possible. Specifically, one resident with a history of falls was left unattended and subsequently fell out of bed, receiving an eye laceration. The deficient practice for this resident was cited at a harm level. In addition, one resident with a history of falls was observed to not have interventions in place, and one resident was left unattended at the side of his bed. Resident identifiers: 27, 41 and 146. [Cross refer to F689] 6. Based on interview, observation and record review, the facility did not ensure that 3 of 54 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level for all three residents. Resident identifiers: 33, 47, and 244. [Cross refer to F692] 7. Based on interview, observation and record review, the facility did not ensure that pain management was provided to 2 of out 54 residents. Specifically, residents complained of pain but were not provided with pain relief medication in a timely manner. These findings resulted in harm for both residents. Resident identifiers: 22 and 298. [Cross refer to F697] 8. On 5/28/21 an annual recertification survey was conducted. Among the deficiencies cited included F550, F584, F600 (at a harm level), F609, F656, F677, F689 (at a harm level), F690 (at a harm level), F695, F697 (at a harm level), F756, and F835. The deficiencies listed were cited again during the current recertification survey. 9. On 6/1/22 a complaint survey was conducted. F880 was cited at that time. F880 was also cited again during the current recertification survey. 10. On 11/3/22 a complaint survey was conducted F550, F677, and F689 were cited. These deficiencies were cited again during the current recertification survey. On 1/30/23 at 3:37 PM, an interview was conducted with the facility Director of Nursing (DON). The DON was asked about the Quality Assurance program, and specifically what had been implemented with regard to brief changes for example. The DON stated that facility CNAs were provided a sheet to document if a resident received a brief change, and how often they should be checked. The DON stated that facility staff should be checking residents' incontinence briefs every couple of hours. When asked how the facility management was ensuring that briefs were being changed timely, the DON stated that facility staff were asking the [CNAs] if they have done their brief changes. On 1/30/23 at 3:17 PM, an interview was conducted with the facility Administrator (ADM). The ADM was asked about the Quality Assurance program, and specifically what had been implemented with regard to brief changes for example. The AM was asked what interventions had been put into place since November 2022 when the facility was cited for F677 after multiple residents were identified as not having their incontinence briefs changed in a timely manner. The ADM stated that they the CNA Coordinator was reviewing the electronic health record documentation to ensure the staff were documenting brief changes. When asked if there was a specific auditing process in place, the ADM stated there was not. When asked if observations were being made by facility management to ensure brief changes were occurring versus being documented, the ADM stated that intervention had not been put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation it was determined, for 1 of 51 sample residents, that the facility did not provide care to prevent unavoidable pressure ulcers, nor did they provide timely treatment and services for the resident's pressure ulcer. Specifically, a resident developed an unstageable pressure sore and was not provided interventions to prevent the pressure sore. In addition, after the pressure sore was developed treatment and services were not provided in a timely manner to heal the pressure sore. This resulted in a finding of harm. Resident identifier: 108. Findings include: Resident 108 was admitted to the facility on [DATE] with diagnoses that included pneumonia, muscle weakness, difficulty in walking, need for assistance with personal care, cognitive communication deficit, heart failure, dementia, urinary tract infection, hyperlipidemia, hypertension, diabetes, and chronic pain. Resident 108's medical record was reviewed on 5/23/21. On 4/29/21, staff completed an Initial admission Record for resident 108. The admission record indicated that resident 108 had a blister on left heel, old pressure wound on coccyx. There were no measurements or description of either wound. On 4/30/21, staff completed an Initial admission Record for resident 108. The admission record indicated that resident 108 had a blister on left heel, old pressure wound on coccyx. There were no measurements or description of either wound. On 4/30/21, staff completed a document entitled Functional Performance Evaluation. The evaluation indicated that resident 108 required substantial/maximal assistance with sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed to chair transfer. On 4/30/21, staff completed a document entitled Braden Scale for Predicting Pressure Sore Risk. The document indicated that resident 108 was slightly limited in her ability to respond to pressure-related discomfort, had skin that was occasionally moist, was chairfast, and was slightly limited in her ability to change and control body position. The document also indicated that resident 108 was at low risk for developing a pressure sore. On 4/30/21 staff developed a care plan for resident 108 that indicated resident had a self care performance deficit related to immobility and weakness. The care plan indicated that resident 108 required Extensive assistance 2 staff participation to reposition and turn in bed. On 5/3/21 staff completed a weekly skin evaluation. Staff indicated that there were no wounds, and no new skin issues. On 5/10/21 staff completed a weekly skin evaluation. Staff indicated that there were no wounds, and no new skin issues. Nurses notes for resident 108 indicated the following note: On 5/12/21 wound team note. team notified 5/11 of sores present on admit. [Resident 108] has MASD (moisture associated skin damage) under L (left) breast, center to L [NAME] (sic), and BL (bilateral) buttock, scaring (sic) noted on BL buttocks from old wounds. she has a fluid filled blister on her R (right) heel, 4.7x4.5xUTD (unable to determine). PI (pressure injury) unstageable. dark in color. no drainage. no s/s (signs or symptoms) of infection. [NAME] (Decubitis ulcer) noted on the L pad of foot. old and very stable, 0.5x0.7xUTD. education on offloading. On 5/12/21 staff developed a care plan for resident 108 that stated Has pressure ulcer development to R (right) heel r/t (related to) immobility. The care plan also stated that the pressure ulcer was present on admission, was unstageable, and was 4.7 centimeters by 4.5 centimeters in size. On 5/12/21 staff also developed a care plan for resident 108 that stated resident 108 Has actual impairment to skin integrity r/t MASD. [Note: The initial skin integrity care plan for resident 108 developed on 4/30/21 did not indicate that resident 108 had any impairments to her skin integrity.] Resident 108's physician orders were reviewed. On 5/12/21, resident 108 had an order written for Wound care to L pad of foot: [NAME], and Wound care to R heel: PI unstageable. No orders for wound care were written prior to 5/12/21. On 5/18/21 staff completed a weekly skin evaluation. Staff documented that resident 108 had an unstageable pressure ulcer to her R heel that was present on admission. However, no notes could be located in resident 108's medical record to indicate that resident 108 had any skin issues on her R heel prior to 5/11/21. In addition, nurses notes did not indicate that the wound team was notified of any skin issues prior to 5/11/21. On 5/19/21 Wound Assessment Progress Note was completed by a wound specialist. The note indicated that resident 108 had an unstageable pressure ulcer on her right heel that was 4.7x4.5xUTD in size. The note also indicated the that wound was intact, dark discoloration [with] fluid and boggy. The note indicated that resident 108 had a skin issue on her left heel that was resolved. On 5/28/21 at 2:00 PM, an interview was conducted with the facility Wound Nurse (WN). The WN stated that resident 108's heel should not be placed directly on the bed or a pillow. The WN stated that resident 108 doesn't have a lot of mobility in her right leg. The WN stated that resident 108 would try to lift her R leg but doesn't succeed. The WN stated that resident 108 was admitted with a blister to her right heel. When asked why there was no documentation about a wound to her R heel prior to 5/11/21 or treatment implemented prior to 5/12/21, the WN stated he did not know. On 5/24/21 at 2:32 PM, an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated that resident 108 could move her leg a little bit. CNA 6 stated that resident 108's heels were supposed to be floated during the day. CNA 6 stated that she was supposed to do rounds on resident 108 every two to three hours. CNA 6 stated that rounds included repositioning resident 108 because resident 108 required staff assistance to reposition herself in bed. On 5/28/21 at 1:50 PM, an interview was conducted with Registered Nurse (RN) 8. RN 8 stated that he was unsure how resident 108's pressure ulcer started. RN 8 stated that resident 108 could not reposition herself in bed. On 5/24/21 at 11:05 AM, an interview was conducted with resident 108. When asked about her stay, resident 108 stated I'm not getting very good care here. Resident 108 stated that she had pain a lot in my back and two sores on my butt. When asked if she could move herself around in her bed, the resident stated she did not attempt to reposition herself in bed because it hurts too much. The resident also stated that she had a sore on her right heel and it hurts like hell. I think it's because I'm just laying in bed. I can wiggle my toes but I can't move my foot off the pillows. It's damn scary to be worried about my foot . On 5/25/21 at 1:23 PM, a follow up interview was conducted with resident 108. Resident 108 stated that staff repositioned her in bed but they don't do it very often. I'll have to call for someone to help. The resident stated that she also had two painful sores on her bottom, that she was admitted with, but my butt feels like its on fire. It needs to be moved. On 5/24/21 a continuous observation was made of resident 108 as follows: a. At 11:35 AM, resident 108 was observed to be in her room in seated her bed, with the head of the bed elevated, and her legs outstretched toward the end of the bed. b. At 12:33 PM, a staff member entered the room to deliver resident 108's lunch tray. c. At 1:10 PM, the Social Services Worker (SSW) entered the room, seated herself in a chair, and spoke with resident 108 for several minutes. d. At 1:23 PM, a staff member entered resident 108's room and obtained a blood glucose sample. e. At 1:41 PM, a staff member entered resident 108's room and administered resident 108's insulin. f. At 2:22 PM, a staff member entered resident 108's room to assist resident 108 out of bed and into her wheelchair. During the duration of the observation from 11:35 AM to 2:22 PM, no staff members were observed to reposition resident 108, nor did resident 108 make any efforts to reposition her buttocks or her legs. On 5/28/21 at 12:55 PM, two staff members were observed to enter resident 108's room. They slid resident 108 up in bed, but did not reposition her right heel. The right heel was observed to be directly laying on a pillow, instead of being floated. On 5/28/21 at 10:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility did not have a policy regarding pressure sore prevention or treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** POTENTIAL FOR HARM 3. Resident 37 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, functional quadriplegia, chronic pain, gout and neuromuscular dysfunction of bladder. On 5/27/21 at approximately 9:53 AM, an interview was conducted with the DON. The DON stated that the facility's smoking program was that upon admission, the resident read and signed the facility's Smoking Policy to acknowledge that they understood the facility's smoking rules. The DON stated that the resident was given information on the smoking times and location for the care unit they reside in. The DON stated that the resident was then evaluated by facility staff to determine if the resident was safe to smoke independently or if there was a need for supervision when they were smoking. The facility's Smoking Policy (Revised 3/2008) revealed the following: Policy: It is the policy of this facility to provide to its' residents a smoke free environment. It is also policy to provide those residents who choose to smoke a means in which to do so that does not jeopardize their safety or the safety of other residing in the facility. Procedure: 1. 2. Upon admission (7-10 days), residents who desire to smoke will be assessed as well as their ability to do so safely. The Interdisciplinary Team will accomplish this using the Smoking Assessment form and a review of the resident's clinical record. At the end of this period it will be determined if the resident will be allowed to smoke with or without protective devices. 3. All resident will be on supervised smoking. 4. The results of the evaluation will be put in the resident's chart. 5. Upon annual review by the IDT (interdisciplinary team), or at any time a significant change of condition occurs, smoking residents will be reassessed as to their ability to smoke safely with or without protective devices and their ability to understand and comply with facility non-smoking policy using the Smoking Assessment form. 7. The frequency of smoking for all residents will be the following times (posted at nurses station) with staff supervision. These times will be no more than twenty (20) minute increments or 2 cigarettes. 8. All smoking materials are to be left at nurses station. [Note: There was no mention in the facility's Smoking Policy about allowing resident to smoke independently if they leave the facility's property or providing smoking materials when a resident wanted to leave the facility's property to smoke.] On 5/27/21, resident 37's medical record was reviewed. Resident 37's Care Plan dated 4/1/21 revealed Potential for injury r/t (related to) Smoking. A goal developed was Will be compliant with smoking protocols and individual smoking plan until next review. Another goal was Will have no injuries related to smoking. Interventions developed were Complete smoking assessment. Explain smoking policy. Maintain smoking materials at nurses' station or other designated area. Monitor to assess compliance with facility smoking policy/individual plan. Observe smoking while in designated area. Report non-compliance or unsafe smoking habits to MD and responsible party. Resident 37's Smoking Agreement that he signed on 4/6/21 revealed .3. I agree to abide by individual restrictions related to smoking safety based on the facilities interdisciplinary team's assessment of my ability to smoke responsibly and safely. [Note: No smoking safety evaluation/assessment was found in resident 37's medical record.] On 5/27/21 at approximately 12:23 PM, an interview was conducted with Certified Nursing Assistant 1. CNA 1 stated that resident's, who smoked could not have their own lighter and they could only have one cigarette, but she give them whatever they want. CNA 1 further stated that residents, who smoked have to be able to wheel themselves out and light the cigarette themselves. CNA 1 stated if residents wanted to smoke on the facility's property, then they would only go during the scheduled times. On 5/27/21 at approximately 6:00 PM, resident 37 was observed near the nurses' station asking CNA 2 for a cigarette. CNA 2 first replied that he could not have a cigarette and stated that smoking is a privilege here. Resident 37 replied back to CNA 2 that she knew he could go smoke anytime he wanted as long as he went off the facility's property. CNA 2 then provided a cigarette and lighter to resident 37. Resident 37 wheeled himself in his wheel chair down the hall and outside. On 5/27/21 at approximately 6:16 PM, an interview was conducted with CNA 2. CNA 2 stated that the smoking times for residents to smoke had recently changed about 3 weeks ago. CNA 2 stated that the facility used to allow smoking 5 times a day, but they did not have enough staff to supervise residents outside smoking so the facility decreased smoking for residents to only 3 times a day. CNA 2 pointed out a sign posted near the nurses' station, which revealed 3 times a day when residents could smoke (10:30 AM, 2:30 PM & 6:30 PM). CNA 2 then stated that resident, who smoked independently, could smoke whenever they want as long as they went off the facility's property. CNA 2 stated that nursing decided if resident were safe to smoke independently. On 5/27/21 at approximately 6:27 PM, resident 37 was observed wheeling himself in his wheel chair coming back toward the nurses' station. An interview was conducted with resident 37. Resident 37 stated that he had become tired of only being able to smoke during the posted times and only out in the courtyard. Resident 37 stated that a couple months ago that the CNA Coordinator told him that he could smoke whenever he wanted as long as he went off of the facility's property. Resident 37 stated he had enjoyed going to smoke when he wanted to and he liked leaving the facility's property to smoke because it gave him some new scenery rather than just going to the facility's courtyard. Resident 37 stated that he usually smoked 2 to 3 times a day and went off property to smoke. On 5/27/21 at approximately 7:18 PM, an interview was conducted with the DON. The DON stated that the facility's smoking times were recently changed because there were too many staff outside supervising smokers rather inside assisting residents. The DON stated that they allowed residents, who smoked safely independently to leave the facility's property to smoke. The DON stated that residents, who smoked were evaluated to determine if they could smoke safely without supervision. The DON stated that resident 37 should have had an evaluation to assess whether he could smoke safely without supervision. 2. Resident 103 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, mild cognitive impairment, hyperlipidemia, and edema. Resident 103's medical record was reviewed on 5/24/2021 through 5/28/2021. A nursing progress notes dated 2/11/21 at 2:48 PM by RN 6, revealed, Has burns on the back of her neck. Stated that resident heat up a wet wash rag in the microwave and put it on her neck unsupervised. resident education about hot pack use with supervision was completed and she understood well. abx (antibiotic) ointment for burns was applied. she tol (tolerated) well. MD (Medical Doctor) notified. DON notified. Resident 103's Treatment Administration Record (TAR) and Medication Administration Record (MAR) for February 2021 were reviewed. There was no documentation of treatment for the burn. Resident 103's orders were reviewed and there were no orders for a burn treatment. On 5/24/21 at 1:15 PM, an interview was conducted with resident 103. Resident 103 stated she asked staff to put a wash rag on her back because she was unable to get a hot pack from the therapy department. Resident 103 stated a CNA warmed up a wet wash cloth and did not check with the nurse. Resident 103 stated that her skin was red. On 5/27/21 at 5:44 PM, an interview was conducted with RN 6. RN 6 stated that the therapy staff members have hot packs for residents. RN 6 stated CNAs should not provide any heated item for residents to put on their bodies. RN 6 stated that she heard from the night shift nurse that resident 103 had sustained a burn on her shoulders. RN 6 stated she was unable to remember who the night shift nurse was. RN 6 stated that she explained to resident 103 to not let CNAs heat up things to place on her body. RN 6 stated that she applied an ointment to the red skin. RN 6 stated resident 103 stated it was painful and felt better after the ointment was applied. RN 6 stated that resident 103 stated she was not aware of how hot the wash cloth was until the washcloth was removed. RN 6 stated that she reported to MD and they said to apply the ointment until healed. RN 6 stated that she notified the DON and did not hear back from the DON. RN 6 stated she educated CNAs not to heat wash cloths and all hot packs were to be applied by therapy staff. On 5/27/21 6:04 PM, an interview was conducted with the DON. The DON stated there were no incident reports or investigation information regarding resident 103's burn. The DON stated he was not aware of the incident. The DON stated that if it was documented that he was notified then he had been notified. The DON stated that he did not complete any systemic changes after the incident. The DON stated that he would have told nurse to notify the MD. The DON stated that he would have educated staff and resident. Based on observation, interview and record review it was determined, for 3 of 51 sample residents, that the facility did not ensure residents received adequate supervision and assistance devices to prevent accidents. Specifically, one resident was assisted with a brief change with only one staff member instead of two, resulting in the resident falling out of bed and sustaining a head laceration. This incident was found to have occurred at a harm level. In addition, a resident sustained a burn after a staff member placed a wet wash cloth from the microwave on the resident. This incident was found to have occurred at a harm level. Another resident was not assessed to determine if he was safe to smoke independently. Resident identifiers: 1, 37, and 103. Findings include: HARM 1. Resident 1 was admitted on [DATE] with diagnoses that included functional quadriplegia, diabetes mellitus, chronic respiratory failure with hypoxia, dysphagia, muscle weakness, , hypertension, difficulty walking, atrial fibrillation, and morbid obesity. Resident 1's medical record was reviewed on 5/23/21. Resident 1's quarterly Minimum Data Set (MDS) admission assessment dated [DATE] was reviewed. The MDS indicated that resident 1 required extensive assistance with 2 staff members for bed mobility, and was totally dependent on 2 staff members for transferring. Resident 1's care plan dated 2/23/21 was reviewed. The care plan indicated that resident 1 required extensive staff participation to reposition and turn in bed. Nurses notes for resident 1 revealed the following: a. On 5/12/21 at 8:00 PM, CNA found RN (Registered Nurse) and alerted her that patient had fallen out of bed during a brief change and was on the floor. CNA states she was changing the resident when she ran out of wipes. She told the resident to go ahead and roll back while she went and got more wipes. The resident then rolled forward rolling off the bed and onto the floor instead of rolling backwards onto her back. CNA returned to the room to find the resident on the floor. Resident head was resting on the stand holding the ventilator and posterior head was actively bleeding . Res (Resident) c/o (complains of) pain all over body and especially her head. Res was assisted back into Bed and Posterior head was clean and area assessed. 1.5 inch laceration and goose bump noted to posterior head . NP (Nurse Practitioner) notified and gave orders to transport Res to [name of local emergency room] . b. On 5/13/21 at 1:20 AM, Resident was transferred back to facility via [name of ambulance company] 3 staples noted to laceration on posterior head. Res Noted to have bruised ribs. Staples to be removed 5/19/21. Resident 1's Medication Administration Record (MAR) indicated that resident 1 received a Tramadol for pain on the following dates and times: [Note: Pain scale was 0 to 10 with 0 indicating no pain and 10 indicating excruciating pain.] a. On 5/13/21 at 12:46 PM for pain 10/10 b. On 5/14/21 at 7:57 AM for pain 2/10 c. On 5/14/21 at 7:48 PM for pain 5/10 [Note: Resident 1 did not receive any other Tramadol during the month of May 2021 as of 5/26/21.] The MAR also indicated that resident 1 complained of pain 9/10 during the night shift on 5/12/21. Physical therapy notes dated 5/12/21 documented that resident 1 required maximum assistance for bed mobility training. Physical therapy notes dated 5/14/21 documented that resident 1 was still not feeling like herself after falling out of bed; body aches due to fall. Physical therapy notes dated 5/18/21 documented that resident 1 was extremely anxious and did not want to attempt sitting EOB (end of bed) today either; has taken a big step back since her fall a week ago. On 6/8/21 at 4:00 PM, an interview was conducted with RN 7. RN 7 stated that she was on duty the night that resident 1 fell out of bed. RN 7 stated that there was only one CNA working that night, and it was an agency CNA, who was not familiar with resident 1. RN 7 stated that the CNA working that night had rolled resident 1 on to her side, and then told resident 1 to roll back, but had left the room before making sure that resident 1 was in a safe position. RN 7 stated that she thought resident 1 had somehow rolled forward, resulting in resident 1 hitting her head on the ventilator stand and sustaining an inch-long gash in her head. RN 7 stated that after that incident, resident 1 always insisted on having two people assist her with cares. On 5/23/21, a confidential staff interview was conducted with SM (Staff Member) 2. SM 2 stated that the facility was poorly staffed. SM 2 stated that all the residents on the 500 hall should be 2 person assistance with brief changes. SM 2 stated that it's dangerous how low the staffing was for the 500 hall. SM 2 stated that there was one agency CNA (Certified Nursing Assistant) for the 500 hall one day, and that resident 1 had an accident because there was only one CNA. SM 2 stated that resident 1 was rolled to her side for a brief change. SM 2 stated that the agency CNA left the room to get wipes and resident 1 rolled out of bed. SM 2 stated that when resident 1 rolled out of bed, she hit her head and ended up with staples. SM 2 stated when Agency CNAs worked on the 500 hall there were a lot more accidents. On 5/23/21 at 7:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that after the incident on 5/12/21 with resident 1, we took all agency staff off that hall. Now all staff that are up there are our people or are agency who have trained for that hall and know how to reposition those residents. The DON also stated that the CNA left the resident on her side when she left the room and that the CNA should not have left the resident on her side. She should have laid her (the resident) back down on her back and taken all of the supplies in with her. The DON stated that staff can use 1 person to change resident 1. The DON stated that he had not provided education to staff on how to provide 1 person care. On 5/24/21 at 9:16 AM, an interview was conducted with the Administrator. The Administrator stated that he had seen that we were staffing only 1 aide when we should be staffing 2. The Administrator stated that 2 weeks ago, I told them (management) we had to have 2 CNAs up there (500 hall) because of the care. The Administrator stated that after an incident when a resident rolled out of bed a Quality Assurance (QA) plan was created. On 5/24/21 at 10:30 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 1 needs two people to change her. She's a total assist. CNA 3 further stated that when he changed resident 1's briefs, he always used two people because the bed is kind've small so I can pull her over to the side to give me enough space, so in case she falls forward she falls into the bed. On 5/24/21 at 10:55 AM, an interview was conducted with resident 1. Resident 1 stated that she was unable to move herself around in bed. When asked about the incident on 5/12/21, resident 1 stated that there were usually two people that changed her brief, but on 5/12/21 it was only one. Resident 1 stated that the lone staff member had rolled the resident to her right side on the edge of the bed and left the room. Resident 1 stated that she had subsequently fallen out of the bed and hit her head on the equipment next to her bed. Resident 1 stated that it was scary. On 5/26/21 a confidential staff interview was conducted with SM 11. SM 11 stated that all the residents on the 500 hall should be assisted by two staff members with brief changes, transfers etc. SM 11 stated that he/she had worked on the 500 hall alone multiple times. SM 11 stated that if there was not another staff member to assist him/her, then he/she would ask the resident, and if the resident says they are ok with me doing stuff by myself I do it. SM 11 stated that after resident 1's fall on 5/12/21, resident 1 doesn't trust anyone [to work with her] by themselves anymore.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record the review, for 6 of 51 sample residents, it was determined that the facility did not ensure that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, the facility failed to ensure proper care for a resident with a urinary catheter which resulted in the resident being hospitalized . This finding was cited at a harm level. In addition, a resident was not toileted timely, resulting in the resident having skin breakdown. This finding was also cited at a harm level. In addition, residents were not placed on a bowel and bladder training program despite requests and staff assessment of appropriateness Resident identifiers: 37, 82, 84, 99, 102, and 112. Findings include: HARM 1. Resident 84 was admitted to the facility 1/1/21. He has a history of traumatic subdural hemorrhage, nontraumatic subarachnoid hemorrhage, falls, tracheostomy, neuromuscular dysfunction of the bladder, chronic respiratory failure, quadriplegia, dependence on respirator, insomnia, Parkinson's disease and dementia. Resident 84's medical record was reviewed on 5/23/21. On 5/20/21 at 10:23 PM, a nursing progress note indicated that resident 84's Foley cath (catheter) is patent and draining well at this time. On 5/22/21 at 7:48 PM, a nursing progress note indicated that res (resident) continued with no urine output since cath change to collect UA (urinalysis) and diaphoresis. MD order received at 1850 (6:50 PM) to transport resident to [name of local emergency room]. [Name of local city paramedics] arrived at 1910 (7:10 PM) to transport and left at 1930 (7:30 PM). The nurses note did not indicate the date or time the catheter had been changed. On 5/22/21 the emergency room Report for resident 84 indicated that the facility staff note that they went to change the patients foley catheter today for source control and had not had urine output since. They also note change in trach (tracheostomy) sputum upon suctioning from clear to green. emergency room Physician diagnoses included acute sepsis, pneumonia (ventilator associated), acute UTI (urinary tract infection). The emergency room Report also documented that a urinalysis indicated red colored urine, turbid in nature, nitrites present in abnormal nature, large amount of hemoglobin, proteins present at greater than 3000, Large abnormal [NAME] Blood Cells and bacteria 3 plus. On 5/22/21, a Computerized Tomography scan was performed in the Emergency Room. The impression from the radiologist included prominently distended bladder. The foley catheter is malpositioned, the balloon is just inferior to the prostal gland. There is bilateral hydroureter with bilateral hydronephrosis, likely secondary to bladder outlet obstruction. On 5/25/21 at 10:06 AM, a record review showed a late entry progress note for 5/23/21 regarding resident 84. The nursing progress note stated that resident 84 was hospitalized on [DATE]. The note also stated that patient was reported to be tachy (tachycardic) with a HR (heart rate) reaching 145 and a low grade fever. Patient was assessed and on call was notified of the change at 1000 (10:00 AM). Orders were received to do CBC (complete blood count) and CRP (C-Reactive Protein). Due to patient being very dehydrated and all staff efforts being without good outcome, [primary physician]had to be contacted to get a PIV (peripheral intravenous) to draw from as well as have a line in place. [Primary physician] placed PIV at 1715 (5:15 PM) and sample was taken to the lab. No urine output had been seen since midmorning and RN (Registered Nurse) suspected it clogged and was told to change it to get culture. catheter was changed at 1500 (3:00 PM) and no urine was produced. RN notified on call. On call at 1845 (6:45 PM) called and told the night RN to send patient out. [Note: It should be noted that resident 84's physician orders indicated that resident 84 was exclusively hydrated and fed via a feeding tube, therefore it is unclear how resident 84 became dehydrated as indicated in the nurses progress note on 5/23/21.] On 5/23/21 a confidential staff interview was conducted with Staff Member (SM) 2. SM 2 stated that resident 84 should have been rounded on every two hours. SM 2 stated that the facility was so short staffed on multiple occasions that the staff wasn't able to check the fullness of residents' catheter bags. SM 2 stated that he/she frequently saw resident catheter bags filled to capacity, as well as residents' catheter bags not being emptied timely. SM 2 stated that on the day of hospitalization, resident 84's catheter was not flowing and the catheter bag was full. SM 2 stated the resident's physician was notified, and the catheter was changed to get clean urine for a urinalysis. SM 2 stated that the new catheter was not draining, and resident 84 then had a bladder scan with no reading. SM 2 then stated that resident 84's physician requested that resident 84 be sent to the local emergency room. SM 2 stated that he/she felt the resident was septic because no one changed resident 84's catheter bag in a timely manner. 2. Resident 112 was admitted to the facility on [DATE] and 1/1/19 with diagnoses which included multiple sclerosis, benign prostatic hyperplasia with lower urinary tract symptoms, mononeuropathy, and dementia with behavioral disturbance. On 5/24/21 at 10:02 AM, an interview was conducted with resident 112. Resident 112 stated that he needed his brief to be changed. Resident 112 was observed to have a foul odor. Resident 112 stated that he wanted to have his brief changed every 2 hours, but was not allowed to be changed until 4 hours had passed. Resident 112 stated that he had not been continent for most of his life. Resident 112 stated that he had a red buttocks and back from sitting in his urine for long periods of time. At 10:30 AM, a therapy staff member wheeled resident to the therapy gym. At 12:40 PM, resident 112 was observed outside the dining room in his wheelchair. Resident 112 stated he still had not been changed. At 1:19 PM, an observation was made of resident 112's buttocks and backside, with CNA 12 and CNA 14 buttocks present. Resident 112 was observed to have red areas with a small opening that were bleeding. On 5/24/21 at 1:25 PM, an interview was conducted with CNA 10. CNA 10 stated that resident 112 was compliant with brief changes. CNA 10 stated that resident 112 had set times to have his brief changed. CNA 10 stated usually after smoking the resident was changed. CNA 10 stated that resident 112's butt is terrible. CNA 10 stated that she slathered the resident's buttocks with cream. CNA 10 stated that the resident's red buttocks were from sitting in a soiled brief for too long and not being changed. CNA 10 stated she also thought the bleeding was from hemorrhoids. On 5/24/21 at 1:30 PM, an interview was conducted with CNA 12. CNA 12 stated that she changed resident 112's brief when he got up this morning. CNA 12 stated that therapy did not do brief changes. CNA 12 stated that resident 112 had sores and dead skin on his buttocks. CNA 12 stated that sometime resident 112's back side bleeds like it did today. CNA 12 stated that resident 112 should have been changed around his smoke break which was about 10:30 AM. CNA 12 stated that another CNA should have changed his brief before the resident left for therapy. CNA 12 stated resident 112 did not have a brief change until 1:30 PM. Resident 112's medical record was reviewed 5/24/21 through 5/28/21. A quarterly MDS dated [DATE] revealed resident 112 was frequently incontinent of bowel and bladder. Resident 112 had not been on a toileting program for bowel or bladder. Resident 112 had a BIMS of 11 which revealed mild cognitive impairment. A care plan dated 5/19/15 revealed, Has bowel incontinence r/t MS (multiple sclerosis) The goal developed was Will have less than two episodes of incontinence per day through the review date. The interventions developed were Check resident [with] rounds and prn (as needed) and assist with toileting as needed and Provide pericare after each incontinent episode. According to the CNA documentation in the tasks section from 4/29/21 until 5/28/21 resident 112 had 4 continent bowel episodes and 1 continent bladder episode. CNA documentation further revealed that resident 112 was documented as being toileted at 7:40 AM. Resident 112's Bowel and Bladder Evaluation dated 1/28/21 and 4/28/21 resident 112 was an unlikely candidate for bowel and bladder re-training. The evaluation dated 4/28/21 revealed that resident 112 was always incontinent of bowel and bladder which made resident an unlikely candidate for re-training. On 5/24/21 at 12:45 PM, an interview was conducted with CNA 10. CNA 10 stated resident 112 was usually changed every 2 hours. CNA 10 stated that resident 112 was able to verbalize to staff when he needed to have a brief changed. CNA 10 stated it can be difficult when staffing is low to change resident 112 because he required 2 person assist with a hoyer lift. On 5/24/21 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 112 was a 2 person assist with brief changes. The DON stated that resident 112 should receive a brief change every 2 hours. On 5/27/21 at 3:43 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated stated that resident 112 was continent but he was hard to transfer so he used briefs. RN 3 stated that resident 112 was alert and Oriented x 4 (person, place, time, and situation). RN 3 stated that resident 112 knew what he wanted and where he was. RN 3 stated that resident 112 was able to tell when he had a brief change. RN 3 stated that she was not aware of any skin issues and nothing had been reported to her regarding the resident's buttocks. RN 3 stated resident 112 was not on a bowel and bladder retraining program. On 5/28/21 at 10:52 AM, a follow up interview was conducted with the DON. The DON stated that resident 112 was alert and oriented for the most part and able to tell staff what he wanted and needed. The DON stated that the resident was compliant with cares as long as it was not during a smoking break. The DON stated that he talked to the Wound Nurse regarding resident 112's buttocks. The DON stated that resident 112 had Moisture Associated Skin Damage (MASD) which was caused by sitting in his urine for too long. POTENTIAL FOR HARM 3. Resident 82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic respiratory failure with hypercapnia, morbid obesity, diabetes, lymphedema, and anxiety disorder. On 5/23/21 at 5:18 PM, an interview was conducted with resident 82. Resident 82 stated that one night she needed to have her brief changed but the 500 hall was short staffed. Resident 82 stated that she had wait all night to be changed. Resident 82 stated earlier today I was changed between 4:00 PM and 4:30 PM. Resident 82 stated prior to that she was changed earlier in the morning. Resident 82 stated she was soaked when she was changed between 4:00 and 4:30 PM. Resident 82 stated that she did not feel safe with Agency staff changing her brief. Resident 82 stated that Agency staff were not trained on how to change her brief safely. Resident 82's medical record was reviewed 5/23/21 through 5/28/21. A quarterly MDS dated [DATE] revealed that resident 82 had a BIMS of 15 which indicated resident was cognitive. The MDS further revealed that resident 82 required 1 person extensive assistance with toilet use and personal hygiene. Resident 82 was not on a trial toileting program and was always incontinent of bowel and bladder. The MDS revealed that resident 82 was at risk for developing pressure ulcers. A care plan initiated on 7/18/18 revealed ADL Self Care Performance Deficit r/t (related to) respiratory failure with obesity hypoventilation syndrome with trach/vent and pulmonary htn (hypertension) . lymphedema. The goal revised on 11/22/2020 by the DON revealed Will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene through the review date. One intervention developed was TOILET USE: Requires one to two person extensive assist to use toilet. [Note: There was no information that resident 82 refused ADL care.] Another care plan dated 7/18/18 and revised on 4/27/20 revealed Has bowel incontinence. The goal was Will remain free from skin breakdown due to incontinence and brief use through the review date. Some of the interventions developed were Ensure there is an unobstructed path to the bathroom. INCONTINENT: Check as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes Another care plan dated 5/19/19 and updated on 5/12/21 by Corporate Resource Nurse (CRN) 1 revealed Actual behavior problem r/t refusing care and vitals to be taken IE pericares, and repositioning [resident 82] will only allow certain aides to take care of her. She will refuse cares if the ones she doesn't like are working. The goal developed was Will have fewer episodes of by review date. Interventions developed were Document behaviors, and resident response to interventions. An intervention dated 5/23/21 by CRN 3 revealed, Provide a log for refusal of care. A review of resident 82's Bowel and Bladder Evaluation forms revealed on 4/27/21 and 1/27/21 she was an unlikely candidate for retraining. According to CNA documentation in the tasks section of resident 82's medical record. Resident was not changed on 4/27/21,4/30/21, 5/8/21, 5/18/21 and 5/21/21 . Resident 82 was changed once during a 24 hour period on 4/25/21, 4/26/21, 5/3/21, 5/4/21, 5/5/21, 5/7/21, 5/11/21, 5/12/21, 5/15/21, 5/19/21, 5/20/21 and 5/22/21. Resident 82 was documented as being changed twice on 5/23/21 which resident 82 confirmed during her interview. There was a binder at the nurses station for resident 82's refusals. According to the form there was a date, concern/refusal, and able to redirect columns on the form. There was nothing documented on 4/27/21, 5/8/21, 5/18/21, or 5/21/21. There was a note on 4/30/21 which revealed resident 82 . refused to be changed or showered by me. Another note revealed, [Resident 82] refused to be changed/showered [and] told us if we turn her light off she was just going to turn it back on. [Resident 82] said I could not change her because of my attitude [and] 'aura.' There was no documentation regarding which staff members talked with resident 82. A form dated 5/16/21 revealed that resident 82 refused to be changed by staff on floor and was requesting a staff member that was not on the scheduled floor and refused four times. The CNA that signed the form was a male CNA and CNA 7 a female CNA. According to the staffing schedule on 5/16/21 provided by the facility DON the male CNA was not listed to be working that day. There was no signature from the resident on the form. According to the Tasks section of the electronic medical record for resident 82 toilet use was completed twice in a 24 hour period on 5/16/21. Resident 82's progress notes revealed the following entries: a. On 2/21/21 at 10:56 AM, . Res incont of BM (bowel movement), frequently refuses to be changed unless specific staff members are available, Briefs are changed when res allows. Redirection and education attempted without success. b. On 3/14/21 at 10:26 PM, Resident refused to be changed by CNA on PM Shift. CNA offered multiple times and resident continued to refuse. c. On 3/15/21 at 4:48 AM, Resident refused to be changed by CNA on NOC (night) Shift. CNA offered multiple times and resident continued to refuse. Residents room smells strongly of urine. Will continue to educate resident on importance of frequent brief changes to prevent UTI (urinary tract infection and skin breakdown. d. On 4/30/21 at 12:14 AM, Resident refused to be changed by female agency aid at 2300. Resident called asking to have brief change and RN informed resident that girl agency aid on 400 hall could come up and change her, resident refused and stated she would wait for am aid. e. On 4/30/21 at 3:08 PM, Patient refused to be changed from 10 pm on 4/29 because she didn't like the aide from an agency. Patient continued to refused care because she did not like the aide was on the floor. Both aides were female and the nurse offered to assist in changing her and told [resident 82] that it wasn't healthy to be sitting in BM for that amount of time. Patient refused and cried and talked about things not relevant to the aides changing her that she was mad about. (an old boss from 20 years ago, ect) RN listened and tried to offer her assistance and come to a resolve but patient was not able to be redirected. Patient refused to be changed and sat in her BM until 1500 (3:00 PM) on 4/30. DON notified. Administrator also came and met with [resident 82] and heard her voiced concerns. Patient still refused cares all day. On 5/24/21 at 10:30 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 82 was only assigned female staff for brief changes and showers per the resident's request. CNA 3 also stated that if you are a new aide or she hasn't seen you before she will refuse all cares. She won't even let you do a brief change. She has only a handful of aides she lets work with her. It's scary because last week she wasn't changed almost all day, but she didn't like the aide that was on that day. The whole hall reeked. On 5/23/21 at 7:33 PM, an interview was conducted with the Administrator. The Administrator stated that resident 82 was particular about who cares for her. The Administrator stated that typically she likes female aides. The Administrator stated that resident 82 wanted to be cared for by specific aides. The Administrator stated that he had talked with resident 82 a lot. The Administrator stated that he was unable to resolve resident 82's concerns. The Administrator stated that he did not file a grievance for resident 82 because he tried to address issues directly. 4. Resident 99 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple Sclerosis, hypertension, major depressive disorder, muscle weakness, and neuromuscular dysfunction of bladder. On 5/26/21 at 10:49 AM, an interview was conducted with resident 99. Resident 99 stated that she had to hold her bowel movements because there were not enough staff. Resident 99 stated that she held her bowel movements during the night shift because there was only one CNA on the 200 hall. Resident 99 stated that CNA 11 was really small and did not know how to operate the sit to stand lift. Resident 99 stated that she did not feel safe with CNA 11 using the sit to stand lift. Resident 99 stated that she skipped meals and did not drink because there were not enough staff to get her up to the bathroom. Resident 99 stated that she was changed at 10:00 PM and then waited till the dayshift CNAs came at 6:00 AM to be changed and put on the toilet. Resident 99 stated that last night she waited for 4 hours to get to the bathroom for a bowel movement. Resident 99 stated that she wanted to use the toilet instead of going in her brief. Resident 99 stated that if she did not have a bowel movement when she was put on the toilet staff will say to her Well, you didn't have to even go. Resident 99's medical record was reviewed 5/25/21 through 5/28/21. A quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which revealed resident was cognitively intact. The MDS revealed that resident 99 did not have a trial toileting program for bowel or bladder. Resident 99 was frequently incontinent of urine. Resident 99 was frequently incontinent of bowel. A care plan dated 12/12/19 revealed Bowel/Bladder: [Resident 99] has requent (sic) bowel/bladder incontinence. The goals developed were Risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date and Will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included Check as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes and Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. [Note: There was no information regarding a retraining program or assisting resident 99 to the toilet.] Another care plan dated 12/19/21 created by CRN 1 and updated on 5/10/21 revealed resident 99 has Multiple Sclerosis and is w/c (wheelchair) dependent. The goal developed was Will maintain optimal status and quality of life within limitations imposed by Disease process through review date, as evidenced by: An intervention developed was Bowel/bladder program to improve or maintain continence PRN (as needed). Resident 99 had a Bowel and Bladder Evaluation completed on 3/24/21 that revealed she was a possible candidate for bowel and bladder retraining. An assessment completed on 2/4/21 revealed that resident 99 was Continent or Good Candidate for retraining. According to the CNA documentation in the tasks section, toilet use did not occur during the night shift on 4/29/21, 4/30/21, 5/1/21, 5/2/21, 5/6/215/9/21, 5/14/21, 5/15/21, 5/17/21, 5/22/21, 5/23/21, and 5/24/21. On 5/27/21 at 1:53 PM, an interview was conducted with CNA 12. CNA 12 stated that multiple residents on the 200 hall had complained to her about CNA 11. CNA 12 stated that she told the CNA coordinator that resident 99 did not want CNA 11 to care for her. CNA 12 stated that residents refused to use the restroom because they did not feel safe during transfers with CNA 11. CNA 12 stated that CNA 11 worked as the only CNA on night shift for the 200 hall. CNA 12 stated that the CNA Coordinator told her that other halls have complained about CNA 11, so we have to make due. On 5/27/21 at 3:49 PM, an interview was conducted with CNA 15. CNA 15 stated there were no residents on a bowel and bladder retraining program. CNA 15 stated resident 99 was incontinent with urine but continent with bowel movements. CNA 15 stated that resident 99 knew when she had urinated. CNA 15 stated resident 99 used 1 person with a sit to stand for transfers to the bathroom. CNA 15 stated that resident 99 complained of other CNAs on the hall that were unable to transfer her because the CNA was not big enough to use the lifts. CNA 15 stated that she usually toileted resident 99 before she left at night so that the resident did not have to get up with CNA 11 during the night. CNA 15 stated she told the CNA coordinator that resident 99 was not comfortable with CNA 11 transferring her. CNA 15 stated that she told the CNA coordinator and Administrator that resident 99 wanted a female CNA only and would not let some CNAs help her. CNA 15 stated that she had been told by residents and other staff that CNA 11 had a hard time using lifts. CNA 15 stated that she stayed late a few times to toilet resident 99 before leaving for the night. 5. Resident 102 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, hypertension, anemia and cerebral infarction due to thrombosis of right vertebral artery. On 5/26/21 at 9:11 AM, an interview was conducted with resident 102. Resident 102 stated she would like to use the toilet verses using a brief. Resident 102 stated staff would take her to the restroom, if they answered her call light. Resident 102 stated it took staff up to an hour to answer her call light. Resident 102 stated that she has had accidents in her pants waiting for staff to answer her call light. Resident 102 stated that if she was able to use the bathroom without help she would get herself to the bathroom so she did not have to use a brief. Resident 102 stated it made her feel like she can't do nothing. Resident 102's medical record was reviewed 5/25/21 through 5/28/21. A annual MDS dated [DATE] revealed that resident 102 had not had a trial of a toileting program for bowel or bladder. The MDS revealed that resident 102 was always incontinent of bladder and frequently incontinent of bowel. Resident 102 had a BIMS of 14 which revealed resident was cognitively intact. A care plan dated 5/20/19 revealed, Has bowel/bladder incontinence. One of the goals developed was Will decrease frequency of urinary incontinence through review date. Interventions included, Offer assistance with toileting with rounds, cares and prn and BRIEF USE: uses disposable briefs. Check/Change with rounds, cares and prn. Another care plan dated 5/7/19 and updated on 5/20/20 revealed ADL Self Care Performance Deficit r/t Immobility and weakness secondary to CVA with hemiplegia affecting left side, Obesity & Incontinence. A goal developed was Will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene; ADL Score through the review date. An intervention developed was TOILET USE: requires Extensive assistance to: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet, to use toilet. A Bowel and Bladder Evaluation dated 10/26/20 revealed that resident 102 was a possible candidate for a bowel and bladder re-training. A Bowel and Bladder Evaluation dated 4/12/21 revealed that resident 102 was an Unlikely Candidate for a re-training program. The form revealed that it was unknown how long resident had been incontinent, always incontinent of bowel and bladder, and was indifferent with behavior/attitude. According to CNA documentation in the tasks section in the last 30 days resident 102 was continent of bowel 4 times and did not have any continent episodes of bladder. On 5/28/21 at 1:29 PM, an interview was conducted with CNA 8. CNA 8 stated that resident 102 really wanted to be continent. CNA 8 stated that a majority of the time she is incontinent. CNA 8 stated that resident 102 was a 2 person pivot transfer. CNA 8 stated resident 102 was not able to transfer herself to use the bathroom. CNA 8 stated that she did not assist resident 102 to the bathroom and had her use her brief. On 5/27/21 at 5:53 PM, an interview was conducted with CNA 13. CNA 13 stated resident 102 did not have any confusion. CNA 13 stated that resident 102 used the toilet for bowel movements. CNA 13 stated resident 102 was able to use the call light and tell staff when she needed to use the bathroom. CNA 13 stated that she assisted resident 102 to the bathroom every 4 hours. CNA 13 stated resident 102 was not on a re-training program for bowel and bladder. On 5/27/21 at 2:41 PM, an interview was conducted with the DON. The DON stated the facility had a new bowel and bladder program. The DON stated that new admissions were monitored for 3 days to determine a bowel and bladder routine. The DON stated if a resident was continent, then the routine would be written on the CNA report sheet. The DON stated that if a resident was more incontinent then maybe they would be put on a re-training program. The DON stated the facility tried to have enough staff to take residents to the bathroom every 1 to 2 hours. On 5/28/21 at 10:52 AM, an interview was conducted with the DON. The DON stated that no residents were on a bowel and bladder re-training program. The DON stated that incontinence care protocol was to change residents every 2 hours. The DON stated that some residents who were continent were able to wait to use the bathroom every 4 hours. The DON stated if a resident was ambulatory then they were taken to the toilet every 2 hours. The DON stated if they were not ambulatory and incontinent then the resident was changed and cleaned every 2 hours. The DON did not know which residents were on a re-training program. 6. Resident 37 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis, functional quadriplegia, chronic pain, neuromuscular dysfunction of bladder, and urinary retention. Resident 37's medical record was reviewed on 5/23/21. On 11/26/20, an admission MDS assessment was completed by staff for resident 37. The MDS indicated that resident 37 was always incontinent of both bowel and bladder, and that the resident was not on a toileting program. A bowel and bladder evaluation dated 11/22/20 was filled out upon resident 37's admission. The evaluation indicated that the resident was incontinent of bowel, but showed willingness to do a training program. The evaluation indicated that resident 37 was a good candidate for bowel and bladder training. The evaluation did not indicate that resident 37 was incontinent of bladder, as indicated by resident 37's MDS. On 3/29/21, a quarterly MDS assessment was completed by staff for resident 37. The MDS indicated that resident 37 was always incontinent of both bowel and bladder, and that the resident was not on a toileting program. Resident 37's care plan was reviewed. The resident's care plan did not indicate that resident 37 was on a bowel and bladder training program, nor did it address resident 37's needs with regard to his bowel and bladder incontinence. On 5/23/21 at 4:06 PM, an interview was conducted with resident 37. Resident 37 stated that he had been asking staff to be on a bowel and bladder training program, and that he had spoken with Restorative Nurse Aid (RNA) 1 about it, but had not been started on a program yet. On 5/28/21 at 11:30 AM, an interview was conducted with RNA 1. RNA 1 stated that the facility had not initiated a bowel and bladder training program for resident 37, but that resident 37 has been wanting to do it. On 5/28/21 at 10:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility did not currently have any residents on a bowel and bladder training program. The DON stated the the facility did not have a policy about bowel and bladder training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record the review, for 3 of 51 sample residents, it was determined that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident experienced uncontrolled pain from a hip fracture for at least six hours prior to being sent to the hospital. This resulted in a finding of harm. In addition, the nursing staff did not provide oral or topical pain medication to residents who were complaining of pain. Resident identifiers: 17, 53 and 110. Findings include: HARM 1. Resident 110 was admitted on [DATE] with diagnoses which included a history of dementia with behavioral disturbance, displaced interochanteric fracture of right femur, convulsions, anemia, cognitive communication deficit, dysphagia, type 2 diabetes, anxiety disorder, primary hypertension and major depression disorder. Resident 110's medical record was reviewed 5/23/21 through 5/28/21. Nurses notes for resident 110 revealed the following entries: a. On 3/2/21 at 11:33 AM, a large bruise was located on the resident's right thigh. The nurse did not indicate if the resident was in pain. b. On 3/2/21 at 4:24 PM, Symptoms or signs noted of Condition change: Pain (uncontrolled). RLE (right lower extremity) rotated laterally. The note indicated that the physician had been notified at 4:00 PM. The note did not indicate how long resident %% had been in pain, onset of pain, level of pain, or interventions for pain management. On 3/2/21 at 6:51 PM, R (right) leg is turned laterally and pt (patient) cries out upon attempt to rotate medially. Large R bruise noted on inner R thigh than L (left) leg. NP (Nurse Practitioner) assessed pt (patient) and ordered R hip x-ray. Pt denies pain, except upon palpation of site. [Note: No progress notes had been entered prior to this to indicate when the pain first started, or how it progressed.] c. On 3/2/21 at 10:15 PM, the NP entered a note that After detailed skin check and nursing assessment of shortened and internally rotated R LE with new bruising to upper groin/leg area. Pt was sitting in w/c (wheelchair) yesterday, but unable to get out of bed today d/t (due to) pain. Also c/o (complains of) pain with any slight movement to RLE and pain to R hip with palpation. Xray ordered. Follow up note: Findings of Comminuted acute intertrochanteric fracture of the right hip with comminuted components and pt sent to ER . for further management and orthopedic consult. d. On 3/2/21 at 10:28 PM, a radiology note indicated that the resident had Comminuted acute intertrochanteric fracture of the right hip with comminuted components. e. On 3/2/21 at 10:35 PM, the facility contacted the resident's husband and stated that the physician was recommending the resident be sent out to the hospital. f. On 3/6/21 at 3:18 AM, Resident re-admitted on [DATE] S/P (status post) r hip cephalomedullary nail. Resident 110's March 2021 Medication Administration Record (MAR) revealed that resident 110 had an order to Monitor level of pain every shift. On 3/2/21, facility staff documented that resident 110 did not have any pain for either shift, despite calling the physician for uncontrolled pain at 4:24 PM. The MAR also indicated that from the time the first nurses note was entered at 4:24 PM until the resident was sent out to the hospital at approximately 10:35 PM, no pain medication was administered to the resident, a timeframe of at least 6 hours. An abuse investigation report dated 3/2/21 revealed that Resident reports attempting to transfer self to wheelchair on 3/2/21 and then suffering increased pain leading to being sent to [local] emergency room. Review of an incident report revealed that resident 110 told staff she was transferring from her chair when the injury happened. However, according to a 12/10/20 Admission, Minimum Data Set (MDS) Assessment, resident 110 could not state what the date, month or year was. She was assessed as having long term and short term memory problems, as well as severely impaired cognitive skills for daily decision making. In addition the incident report did not indicate what time the resident allegedly fell. On 5/27/21 at 4:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the information about the resident attempting to transfer to the wheelchair was obtained through an interview with the husband. The DON could not provide an explanation as to why resident 110 was in pain from a fractured hip with no pain medication for at least 6 hours. On 5/27/21 at 5:36 PM, an interview was conducted with resident 110's husband. Resident 110's husband stated that resident 110 had a seizure with a fall in February and she was complaining of pain in her lower legs. Resident 110's husband stated that resident 110 was sent to the hospital and her lower legs were X-rayed and there were no fractures. Resident 110's husband stated that a couple weeks later, the facility called him and stated that resident 110 had pain in her right hip with some bruising. Resident 110's husband stated that the facility then sent her to the hospital a second time and she had a fractured hip which required surgery. Resident 110's husband stated he did not witness a fall and was not told about a fall. Resident 110's family member stated that he had not witnessed or been told by facility staff that resident 110 had transferred herself to her wheel chair, sustaining an injury to her hip. 3. Resident 53 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism of right anterior cerebral artery, hypertension, hyperlipidemia, homonymous bilateral field deficits-left side, vascular headache, asthma, low back pain, insomnia, history of falling and dementia. On 5/25/21 at approximately 2:36 PM, resident 53 complained of pain in both shoulders. Resident 53 stated he had taken medication for it but it did not provide relief. Resident 53 stated he told the physician that the Lortab did not provide relief. On 5/25/21 at approximately 2:45 PM, resident 53 reported pain in his chest area. Resident 53 stated, I think I'm having a heart attack. Registered Nurse (RN) 3 stated that resident 53 always had complaints of pain. The Assistant Director of Nursing (ADON) approached and obtained resident 53's vital signs and they were within normal limits. The ADON stated that resident 53 had a diagnosis of gastroesophageal reflux (GERD). Resident 53's medical record was reviewed 5/27/21. Resident 53 had the following medication orders for pain: a. Acetaminophen 1000 mg (milligrams) by mouth two times a day for pain not to exceed (NTE) 3000 mg in a 24 hour period from all sources. Order Date 3/2/21 b. Acetaminophen 1000 mg by mouth every 24 hours as needed (PRN) for pain prn NTE 3000 mg in a 24 hour period from all sources. Order Date 3/2/21 c. Pantoprazole Tablet Delayed Release 40 mg by mouth one time a day for GERD. Order Date 12/18/20 Resident 53 was having his pain assessed twice-a-day, morning and evening, using a pain scale of 0 - 10, where a score of 0 was no pain, and a score of 10 was the worst possible pain. Review of resident 53's April 2021 and May 2021 Medication Administration Records (MARs) revealed the following pain score monitoring while receiving Acetaminophen 1000 mg by mouth twice a day [morning and evening]: April 2021 a. 4/4/21 morning pain score was 3, evening pain score was 1. b. 4/5/21 morning pain score was 4, evening pain score was 1. c. 4/6/21 morning pain score was 2, evening pain score was 1. d. 4/8/21 morning pain score was 8, evening pain score was 0. [Note: An additional PRN pain medication (Acetaminophen 1000 mg) by mouth was administered at 12:21 PM and charted as Effective.] e. 4/9/21 morning pain score was 2, evening pain score was 2. f. 4/10/21 morning pain score was 2, evening pain score was 0. g. 4/11/21 morning pain score was 0, evening pain score was 6. h. 4/12/21 morning pain score was 4, evening pain score was 1. i. 4/13/21 morning pain score was 1, evening pain score was 1. j. 4/14/21 morning pain score was 4, evening pain score was 1. k. 4/15/21 morning pain score was 0, evening pain score was 5. l. 4/17/21 morning pain score was 0, evening pain score was 1. m. 4/18/21 morning pain score was 2, evening pain score was 2. n. 4/19, 21 morning pain score was 2, evening pain score was 1. o. 4/20/21 morning pain score was 2, evening pain score was 0. p. 4/22/21 morning pain score was 0, evening pain score was 4. q. 4/24/21 morning pain score was 2, evening pain score was 0. r. 4/26/21 morning pain score was 3, evening pain score was 1. s. 4/27/21 morning pain score was 1, evening pain score was 1. t. 4/28/21 morning pain score was 1, evening pain score was 1. u. 4/29/21 morning pain score was 0, evening pain score was 1. [Note: No additional PRN pain medication was administered except for the dose on 4/8/21.] May 2021 a. 5/2/21 morning pain score was 3, evening pain score was 0. b. 5/3/21 morning pain score was 3, evening pain score was 3. c. 5/5/21 morning pain score was 0, evening pain score was 10. d. 5/9/21 morning pain score was 5, evening pain score was 5. e. 5/10/21 morning pain score was 4, evening pain score was 0. f. 5/11/21 morning pain score was 4, evening pain score was 0. g. 5/12/21 morning pain score was 4, evening pain score was 4. h. 5/17/21 morning pain score was 4, evening pain score was 2. i. 5/24/21 morning pain score was 2, evening pain score was 1. j. 5/26/21 morning pain score was 2, evening pain score was 0. [Note: No additional PRN pain medication was administered.] On 5/27/21 at approximately 5:42 PM, an interview was conducted with resident 53. Resident 53 stated that his left shoulder pain was an 8 out of 10 on the pain scale. Resident 53 was observed to hold his left shoulder. Resident 53 stated that he told the nurses that this shoulder hurt so it must be his chest, so it must be having a heart attack. Resident 53 was observed to rub his left shoulder. [Note: No additional PRN pain medication was administered until 6:43 PM.] On 5/27/21 at approximately 5:50 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she did not know why resident 53 did not receive any additional PRN pain medication after reporting a pain score of 10 out of 10 on 5/5/21. RN 1 stated that if a resident had reported a pain score of 10 to her, that she would have checked to see if the resident had a PRN pain medication ordered and then would administer it and notify the resident's provider. On 5/27/21 at approximately 6:43 PM, resident 53 was observed grimacing, holding and rubbing both shoulders while standing near the nurses' station. Resident 53 complained of pain in his shoulders and requested his pain medication from RN 2. RN 2 asked resident 53 how he rated his pain. Resident 53 responded that it was an 8 out of 10. RN 2 administered resident 53 his scheduled evening dose of Acetaminophen 1000 milligrams (mg) by mouth with water. On 5/27/21 at approximately 6:50 PM, an interview was conducted with RN 2. RN 2 stated she did not know why resident 53 did not receive any additional PRN pain medication after reporting a pain score of 10 on 5/5/21. RN 2 stated if a resident had reported a pain score of 10 that she would have checked to see if the resident had a PRN pain medication ordered and would have administered it. On 5/27/21 at approximately 7:29 PM, an interview was conducted with the DON. The DON stated that he did not know why resident 53 did not receive any additional PRN pain medication after reporting a pain score of 10 on 5/5/21. On 5/27/21 at approximately 7:40 PM, resident 53 was observed at the nurses' station. Resident 53 stated that he had shoulder pain and no one loves me, no one cares about me. On 5/28/21 at 8:25 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the process for evaluating a resident's pain was by done by the nurse every shift with a pain assessment utilizing a pain scale and with each pain medication administration. The DON stated that if the pain was reported at a higher level the nurse would assess the resident and report it to the physician. The DON stated that for a report of a pain level of a 10/10 (on a scale of 1 to 10, with 10 being the highest), he would expect the nurse to administer a PRN (as needed) pain medication, and then follow up with the physician. The DON stated that if the physician was informed he would expect that the resident would get something additional for the pain, like with a fracture. The DON stated that this would also be dependent on what was the cause of the pain. What is the reason behind this? If it is something big, yes. If its a one time thing, maybe not. With a fracture they get an x-ray and see what is causing the pain and treat the pain. The DON stated that resident 17 had not reported any pain in the arm and knees. The DON stated that resident 17 had Voltaren gel that helped if applied every night. If they are consistent with it, it would really help. The DON stated that resident 53 reported chest pain. The DON stated that resident 53 was not alert and oriented. The DON stated that resident 53 had left the facility before to seek treatment for chest pain and then returned to the facility. The DON then stated that resident 53 was alert and oriented enough to come back to the facility. The DON stated that he was not aware that resident 53 was reporting pain at a level of 8/10 last evening. The DON stated the facility did not have a policy and procedure for pain management. POTENTIAL FOR HARM 2. Resident 17 was admitted to the facility on [DATE] with diagnoses which included femur fracture, muscle weakness, need for assistance with personal care, difficulty walking, respiratory failure, low back pain, and morbid obesity with alveolar hypoventilation. On 5/26/21 at 11:51 AM, an interview was conducted with resident 17. Resident 17 stated his knees and shoulders needed to have Voltaren gel twice a day. Resident 17 stated there were not enough staff to apply the gel twice daily to his shoulders and knees. Resident 17 stated that the gel helped but needed to be applied during the busy times of the day in the morning and before bed. Resident 17's medical record was reviewed on 5/28/21. An order dated 11/16/20 revealed Voltaren Gel 1% apply application transdermally every 6 hours as needed for pain. A quarterly MDS dated [DATE] revealed that resident 17 had scheduled pain medications, as needed medications, and non-medication interventions for pain. A pain assessment was completed and revealed resident had almost constant pain. Resident 17's pain made it had for him to sleep at night and limited his day to day activities. A care plan dated 10/9/20 and updated on 3/25/21 revealed Has acute/ chronic pain r/t (related to) surgical repair of LLE (left lower extremity) fx (fracture), muscle spasms, neuropathy Duloxetine as ordered.Tylenol as ordered, lidocaine gel 0.5% as ordered, Diclofenac as ordered, Pramipexole as ordered oxycodone 5/325mg (milligrams) as ordered, Voltaren gel 1% as ordered. The goals were Will not have an interruption in normal activities due to pain through the review date. Will voice a level of comfort through the review date. Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The interventions developed were Administer analgesia medication as per orders. Give 1/2 hour before treatments or care. Anticipate need for pain relief and respond immediately to any complaint of pain. Report occurrences to the physician. Monitor/record pain characteristics: . Pain assessment every shift. According to the Medication Administration Record for May 2021 resident 17 had Voltaren Gel Applied on the following days with the following pain score [Pain scores were 0 to 10 with 0 indicated no pain and 10 indicated excruciating pain]: a. 5/1/21, 6 and the gel was effective. b. 5/12/21, 8 and the gel was effective c. 5/16/21, 6 and the gel was effective. d. 5/19/21, 3 and the get was effective. e. 5/22/21, 7 and the gel was effective. f. 5/26/21, 10 and the gel was effective. On 5/28/21 at 1:33 PM, an interview was conducted with Certified Nursing Assistant (CNA) 8. CNA 8 stated that resident 17 had Voltaren gel in his drawer in his room. CNA 8 stated he applied it to his shoulders and knees. CNA 8 stated that the gel provided pain relief and he seemed to feel better after the gel was applied. CNA 8 stated that resident 17 asked to have her apply it occasionally. On 5/28/21 at 1:45 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated Voltaren gel was a medication to be administered by the nurse. RN 1 stated that resident 17 had the gel in his top drawer and was able to apply it himself to his knees but needed assistance applying it to his shoulders. On 5/28/21 at 1:50 PM, a follow up interview was conducted with resident 17. Resident 17 stated that he wanted a nurse to apply the gel to his shoulders and knees. Resident 17 stated that the gel really helps with the pain. Resident 17 stated that the nurses were too busy to apply it in the morning and at night. Resident 17 stated that he sometimes asked CNAs to apply it but they were very busy. Resident 17 stated he tried to apply the gel to his shoulders but was unable to reach all the way behind his shoulder. Resident 17 stated he did not apply it to his knees because he was unable to reach his knees and almost fell forward trying to reach them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 51 sample residents, that the facility did not ensure that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practical mental and psychosocial well-being. Specifically, a resident that attempted suicide was not provided mental health services. This was found to have occurred at a harm level. Resident identifier: 99. Findings include: Resident 99 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis, post-traumatic stress disorder, muscle weakness, anxiety disorder and major depressive disorder. On 5/26/21 at 11:22 AM, an interview was conducted with resident 99. Resident 99 stated that she attempted suicide after an agency Certified Nursing Assistant (CNA) treated her terrible. Resident 99 stated there were not enough staff and she felt like a burden on staff. Resident 99 stated that she tried to cut my throat. Resident 99 stated that she used a knife and put a hole in my neck. Resident 99 stated she was supposed to see a counselor after she returned from the hospital. Resident 99 stated that a counselor came into her room and said he was in a hurry and would come back to talk. Resident 99 stated she wanted to talk to a counselor but the counselor had not returned. Resident 99 stated that she had attempted suicide prior to admission as well. Resident 99's medical record was reviewed 5/26/21 through 5/28/21. A care plan dated 5/11/21 revealed, Resident has a history of suicide attempts. A goal developed was Resident will have no incidents of self harm. Interventions were Administer medications as ordered. Monitor/document for side effects and effectiveness, encourage to express feelings, Monitor/record/report to MD prn (as needed) risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med (medications) or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness, provide [local] Mental Health crisis number, resident followed by [local] Mental health. The Emergency Department History and Physical Report dated 3/19/21 at 3:41 PM revealed that resident 99 was .brought in by EMS (Emergency Medical Services), VS (vital signs) normal but pt (patient) unresponsive. Superficial self inflicted abrasion on right arm and chest/neck. The report further revealed, According to caregivers at the facility patient was in her normal state this morning. Her normal state is bedbound only moves right upper extremity and is conversant. Patient had mentioned to some of the workers that she wanted to kill herself. She had a visitor at the facility today. This afternoon patient was found unresponsive with superficial cut marks to her neck. Resident 99's progress notes revealed the entries: a. On 3/19/21 at 1:00 PM, At 1205 (12:05 PM) Aid reported that she went to check in on resident and noticed that resident had a pocket knife in her left hand and noticed that she had a cut on her lower R (right) forearm and bloody smear just below the front side of her neck. She immediately called out to the nurse who was outside the door and while nurse was with the resident she alerted another nurse for help. Upon arriving in residents room, writer noted that the first nurse was holding on to left hand to prevent resident from cutting herself and talking calmly to her. Resident was not combative and was not attempting to attack the staff. She appeared withdrawn, somewhat lethargic but was still coherent to answer appropriately. Staff was able to talk resident into letting the pocket knife go. Resident refused to answer specifically why she was upset. She said repeatedly 'I just want to die', 'I want to be with [name removed]', '[name removed] wants me to be with him', 'Put me in the ground next to [name removed]'. Resident was placed on one on one watch with staff. Provider, DON (Director of Nursing) and Administrator alerted to situation. Provider ordered to send resident to [local hospital] ED (Emergency Department) for further psychiatric and medical eval (evaluation) and treatment for suicidal ideation and action. Family notified of concerns. One of the daughters mentioned that resident has had suicidal ideation and attempts in the past at home and the reason why she was placed in a care center. Resident picked up by [local non-emergent ambulance company] [at] 1250 (12:50 PM) and transported to hospital via stretcher. b. On 3/22/21 at 3:42 PM, MD (Medical Doctor) recommended psych (psychological) evaluation, [local mental health company] notified and coordinating a visit for evaluation. c. On 3/26/21 at 9:43 AM, Late Entry: SW (Social Worker) spoke to [resident 99] about her SI (suicidal ideation) hospitalization and how she was feeling. [Resident 99] stated that she felt better and explained her attempt and what brought her to the ED. SW asked if she had met with the therapist and APRN (Advanced Practice Registered Nurse) that week and she said yes. SW asked if she had any SI ideation that week since returning and she said no. [Resident 99] spoke candidly with SW about her attempts.SW feels she is stable at this time. SW talk to nursing about possible plastic utensils. An Investigation regarding resident 99 suicide attempt was provided to the State Survey Agency. The undated form revealed that on 3/19/21 resident 99 had a suicide attempt. The follow up information revealed, .Resident requested a psychiatric visit to evaluate her mental state. [Local mental Health Company] Mental Health was coordinated to perform visit. Provider did write a new medication order to assist with her psychosocial well-being. House provider was updated on recommendation and order from psychiatric provider to which it was agreed to follow those recommendations. On 5/28/21 at 9:18 AM, a list was provided by the facility Discharge Planner. The list was resident names that the local mental health company was providing services to. Resident 99 was not on the list. The facility Discharge Planner responded that resident 99 was not receiving services but paperwork was being sent today to have resident 99 be on services the following week. On 5/27/21 at 12:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that there was no incident report for resident 99's suicide attempt. On 5/27/21 at 12:26 PM, an interview was conducted with CNA 12. CNA 12 stated that she was not working when resident 99 tried to hurt herself. CNA 12 stated that she worked the following day. CNA 12 stated that resident 99 told her that an agency CNA had told her she was a burden, like her husband always did. CNA 12 stated that resident 99 told her she had a knife or something sharp she pressed into her neck. CNA 12 stated that resident 99 told her that a nurse came in and found her. CNA 12 stated that resident 99 told CNA 12 that she was in the wrong head space. CNA 12 stated that resident 99's routine in the morning was usually an hour long and agency CNAs have been upset her routine was so long and told her she was a burden. On 5/27/21 at 2:00 PM, an interview was conducted with SSW 1. SSW 1 stated she started at the facility February 2021. SSW 1 stated resident 99 had a suicide attempt. SSW 1 stated she spoke with resident 99 after her suicide attempt. SSW 1 stated that resident 99 stated that she grabbed her knife from home after an agency CNA that was working with her was not very kind with her. SSW 1 stated that resident 99 told her she tried to stab herself with the knife. SSW 1 stated resident 99 was sent to hospital and was there for a bit and then came back. SSW 1 stated that when resident 99 returned to the facility a mental health company was contacted to work with resident 99. SSW 1 stated that resident 99 was seeing the mental health specialist weekly. SSW 1 stated she was not involved in care planning. SSW 1 stated she talked to management and the CNA coordinator about not allowing the Agency CNA back in the building. SSW 1 stated that the CNA coordinator contacted Agency CNAs. SSW 1 stated that she had discussed staffing issues with the management team. SSW 1 stated she provided some training for staff on how to deal with emotional and mental issues with residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 7 out of 51 residents, that the facility did not ensure that the residents were free from abuse and neglect. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute sepsis, a resident sustained a fall resulting in a head laceration due to a one person assist when two people were required, a resident with pressure ulcers (PU) located on the bilateral heels did not have the heels floated as ordered and repositioning did not occur for an observed 3 hour time period, and a resident was not provided incontinence care resulting in moisture associated skin damage (MASD) with an open area and a bloody presentation. These examples of neglect were cited at a harm level. Additionally, a resident reported an allegation of verbal and physical abuse from a licensed nurse with medication administration, a resident reported an allegation of physical abuse from a Certified Nurse Assistant (CNA) during incontinence care, and a resident reported an allegation of rough treatment during incontinence care in September 2020 followed by an allegation of verbal abuse with cares by the same nurse in May 2021. Resident identifiers: 1, 17, 84, 101, 105, 108 and 112. Findings include: A. The following examples were cited at harm level for neglect. According to the interpretive guidance neglect was defined as the failure of the facility, it's employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1. Resident 84 was admitted to the facility 1/1/21. He has a history of traumatic subdural hemorrhage, nontraumatic subarachnoid hemorrhage, falls, tracheostomy, neuromuscular dysfunction of the bladder, chronic respiratory failure, quadriplegia, dependence on respirator, insomnia, Parkinson's disease and dementia. Resident 84's medical record was reviewed on 5/23/21. On 5/20/21 at 10:23 PM, a nursing progress note indicated that resident 84's Foley cath (catheter) is patent and draining well at this time. On 5/22/21 at 7:48 PM, a nursing progress note indicated that res (resident) continued with no urine output since cath change to collect UA (urinalysis) and diaphoresis. MD order received at 1850 (6:50 PM) to transport resident to [name of local emergency room]. [Name of local city paramedics] arrived at 1910 (7:10 PM) to transport and left at 1930 (7:30 PM). The nurses note did not indicate the date or time the catheter had been changed. On 5/22/21 the emergency room Report for resident 84 indicated that the facility staff note that they went to change the patients Foley catheter today for source control and had not had urine output since. They also note change in trach (tracheostomy) sputum upon suctioning from clear to green. emergency room Physician diagnoses included acute sepsis, pneumonia (ventilator associated), acute UTI (urinary tract infection). The emergency room Report also documented that a urinalysis indicated red colored urine, turbid in nature, nitrites present in abnormal nature, large amount of hemoglobin, proteins present at greater than 3000, Large abnormal [NAME] Blood Cells and bacteria 3 plus. On 5/22/21, a Computerized Tomography scan was performed in the Emergency Room. The impression from the radiologist included prominently distended bladder. The Foley catheter is malpositioned, the balloon is just inferior to the prostal gland. There is bilateral hydroureter with bilateral hydronephrosis, likely secondary to bladder outlet obstruction. On 5/25/21 at 10:06 AM, a record review showed a late entry progress note for 5/23/21 regarding resident 84. The nursing progress note stated that resident 84 was hospitalized on [DATE]. The note also stated that patient was reported to be tachy (tachycardic) with a HR (heart rate) reaching 145 and a low grade fever. Patient was assessed and on call was notified of the change at 1000 (10:00 AM). Orders were received to do CBC (complete blood count) and CRP (C-Reactive Protein). Due to patient being very dehydrated and all staff efforts being without good outcome, [primary physician]had to be contacted to get a PIV (peripheral intravenous) to draw from as well as have a line in place. [Primary physician] placed PIV at 1715 (5:15 PM) and sample was taken to the lab. No urine output had been seen since midmorning and RN (Registered Nurse) suspected it clogged and was told to change it to get culture. catheter was changed at 1500 (3:00 PM) and no urine was produced. RN notified on call. On call at 1845 (6:45 PM) called and told the night RN to send patient out. [Note: It should be noted that resident 84's physician orders indicated that resident 84 was exclusively hydrated and fed via a feeding tube, therefore it is unclear how resident 84 became dehydrated as indicated in the nurses progress note on 5/23/21.] On 5/23/21 a confidential staff interview was conducted with Staff Member (SM) 2. SM 2 stated that resident 84 should have been rounded on every two hours. SM 2 stated that the facility was so short staffed on multiple occasions that the staff wasn't able to check the fullness of residents' catheter bags. SM 2 stated that he/she frequently saw resident catheter bags filled to capacity, as well as residents' catheter bags not being emptied timely. SM 2 stated that on the day of hospitalization, resident 84's catheter was not flowing and the catheter bag was full. SM 2 stated the resident's physician was notified, and the catheter was changed to get clean urine for a urinalysis. SM 2 stated that the new catheter was not draining, and resident 84 then had a bladder scan with no reading. SM 2 then stated that resident 84's physician requested that resident 84 be sent to the local emergency room. SM 2 stated that he/she felt the resident was septic because no one changed resident 84's catheter bag in a timely manner. 2 . Resident 1 was admitted on [DATE] with diagnoses that included functional quadriplegia, diabetes mellitus, chronic respiratory failure with hypoxia, dysphagia, muscle weakness, , hypertension, difficulty walking, atrial fibrillation, and morbid obesity. Resident 1's medical record was reviewed on 5/23/21. Resident 1's quarterly Minimum Data Set (MDS) admission assessment dated [DATE] was reviewed. The MDS indicated that resident 1 required extensive assistance with 2 staff members for bed mobility, and was totally dependent on 2 staff members for transferring. Nurses notes for resident 1 revealed the following: a. On 5/12/21 at 8:00 PM, CNA found RN and alerted her that patient had fallen out of bed during a brief change and was on the floor. CNA states she was changing the resident when she ran out of wipes. She told the resident to go ahead and roll back while she went and got more wipes. The resident then rolled forward rolling off the bed and onto the floor instead of rolling backwards onto her back. CNA returned to the room to find the resident on the floor. Resident head was resting on the stand holding the ventilator and posterior head was actively bleeding . Res (Resident) c/o (complains of) pain all over body and especially her head. Res was assisted back into Bed and Posterior head was clean and area assessed. 1.5 inch laceration and goose bump noted to posterior head . NP (Nurse Practitioner) notified and gave orders to transport Res to [name of local emergency room] . b. On 5/13/21 at 1:20 AM, Resident was transferred back to facility via [name of ambulance company] 3 staples noted to laceration on posterior head. Res Noted to have bruised ribs. Staples to be removed 5/19/21. Resident 1's Medication Administration Record (MAR) indicated that resident 1 received a tramadol for pain on the following dates and times: a. On 5/13/21 at 12:46 PM for pain 10/10 b. On 5/14/21 at 7:57 AM for pain 2/10 c. On 5/14/21 at 7:48 PM for pain 5/10 [Note: Resident 1 did not receive any other tramadol during the month of May 2021 as of 5/26/21.] The MAR also indicated that resident 1 complained of pain 9/10 during the night shift on 5/12/21. Physical therapy notes dated 5/12/21 documented that resident 1 required maximum assistance for bed mobility training. Physical therapy notes dated 5/14/21 documented that resident 1 was still not feeling like herself after falling out of bed; body aches due to fall. Physical therapy notes dated 5/18/21 documented that resident 1 was extremely anxious and did not want to attempt sitting EOB (end of bed) today either; has taken a big step back since her fall a week ago. On 5/23/21 at 7:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that after the incident on 5/12/21 with resident 1, we took all agency staff off that hall. Now all staff that are up there are our people or are agency who have trained for that hall and know how to reposition those residents. The DON also stated that the CNA left the resident on her side when she left the room and that the CNA should not have left the resident on her side. She should have laid her (the resident) back down on her back and taken all of the supplies in with her. On 5/24/21 at 10:30 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 1 needs two people to change her. She's a total assist. CNA 3 further stated that when he changed resident 1's briefs, he always used two people because the bed is kind've small so I can pull her over to the side to give me enough space, so in case she falls forward she falls into the bed. On 5/24/21 at 10:55 AM, an interview was conducted with resident 1. Resident 1 stated that she was unable to move herself around in bed. When asked about the incident on 5/12/21, resident 1 stated that there were usually two people that changed her brief, but on 5/12/21 it was only one. Resident 1 stated that the lone staff member had rolled the resident to her right side on the edge of the bed and left the room. Resident 1 stated that she had subsequently fallen out of the bed and hit her head on the equipment next to her bed. Resident 1 stated that it was scary. On 5/23/21, a confidential staff interview was conducted with SM 2. SM 2 stated that the facility was poorly staffed. SM 2 stated that all the residents on the 500 hall should be 2 person assistance with brief changes. SM 2 stated that it's dangerous how low the staffing was for the 500 hall. SM 2 stated that there was one agency CNA for the 500 hall one day, and that resident 1 had an accident because there was only one CNA. SM 2 stated that resident 1 was rolled to her side for a brief change. SM 2 stated that the agency CNA left the room to get wipes and resident 1 rolled out of bed. SM 2 stated that when resident 1 rolled out of bed she hit her head and ended up with stitches. SM 2 stated when Agency CNAs worked on the 500 hall there were a lot more accidents. 3. Resident 108 was admitted to the facility on [DATE] with diagnoses that included pneumonia, muscle weakness, difficulty in walking, need for assistance with personal care, cognitive communication deficit, heart failure, dementia, urinary tract infection, hyperlipidemia, hypertension, diabetes, and chronic pain. Resident 108's medical record was reviewed on 5/23/21. On 4/29/21, staff completed an Initial admission Record for resident 108. The admission record indicated that resident 108 had a blister on left heel, old pressure wound on coccyx. There were no measurements or description of either wound. On 4/30/21, staff completed an Initial admission Record for resident 108. The admission record indicated that resident 108 had a blister on left heel, old pressure wound on coccyx. There were no measurements or description of either wound. On 4/30/21, staff completed a document entitled Functional Performance Evaluation. The evaluation indicated that resident 108 requiredsubstantial/maximal assistance with sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed to chair transfer. On 4/30/21, staff completed a document entitled Braden Scale for Predicting Pressure Sore Risk. The document indicated that resident 108 was slightly limited in her ability to respond to pressure-related discomfort, had skin that was occasionally moist, was chairfast, and was slightly limited in her ability to change and control body position. The document also indicated that resident 108 was at low risk for developing a pressure sore. On 4/30/21 staff developed a care plan for resident 108 that indicated resident had a self care performance deficit related to immobility and weakness. The care plan indicated that resident 108 required Extensive assistance 2 staff participation to reposition and turn in bed. On 5/3/21 staff completed a weekly skin evaluation. Staff indicated that there were no wounds, and no new skin issues. On 5/10/21 staff completed a weekly skin evaluation. Staff indicated that there were no wounds, and no new skin issues. Nurses notes for resident 108 indicated the following note: On 5/12/21 wound team note. team notified 5/11 of sores present on admit. [Resident 108] has MASD under L (left) breast, center to L [NAME] (sic), and BL (bilateral) buttock, scaring (sic) noted on BL buttocks from old wounds. she has a fluid filled blister on her R (right) heel, 4.7x4.5xUTD (unable to determine). PI (pressure injury) unstageable. dark in color. no drainage. no s/s (signs or symptoms) of infection. [NAME] (Decubitis ulcer) noted on the L pad of foot. old and very stable, 0.5x0.7xUTD. education on offloading. On 5/12/21 staff developed a care plan for resident 108 that stated Has pressure ulcer development to R (right) heel r/t (related to) immobility. The care plan also stated that the pressure ulcer was present on admission, was unstageable, and was 4.7 centimeters by 4.5 centimeters in size. On 5/12/21 staff also developed a care plan for resident 108 that stated resident 108 Has actual impairment to skin integrity r/t MASD. [Note: The initial skin integrity care plan for resident 108 developed on 4/30/21 did not indicate that resident 108 had any impairments to her skin integrity.] Resident 108's physician orders were reviewed. On 5/12/21, resident 108 had an order written for Wound care to L pad of foot: [NAME], and Wound care to R heel: PI unstageable. No orders for wound care were written prior to 5/12/21. On 5/18/21 staff completed a weekly skin evaluation. Staff documented that resident 108 had an unstageable pressure ulcer to her R heel that was present on admission. However, no notes could be located in resident 108's medical record to indicate that resident 108 had any skin issues on her R heel prior to 5/11/21. In addition, nurses notes did not indicate that the wound team was notified of any skin issues prior to 5/11/21. On 5/19/21 Wound Assessment Progress Note was completed by a wound specialist. The note indicated that resident 108 had an unstageable pressure ulcer on her right heel that was 4.7x4.5xUTD in size. The note also indicated the that wound was intact, dark discoloration [with] fluid and boggy. The note indicated that resident 108 had a skin issue on her left heel that was resolved. On 5/28/21 at 2:00 PM, an interview was conducted with the facility Wound Nurse (WN). The WN stated that resident 108's heel should not be placed directly on the bed or a pillow. The WN stated that resident 108 doesn't have a lot of mobility in her right leg. The WN stated that resident 108 would try to lift her R leg but doesn't succeed. The WN stated that resident 108 was admitted with a blister to her right heel. When asked why there was no documentation about a wound to her R heel prior to 5/11/21 or treatment implemented prior to 5/12/21, the WN stated he did not know. On 5/24/21 at 11:05 AM, an interview was conducted with resident 108. When asked about her stay, resident 108 stated I'm not getting very good care here. Resident 108 stated that she had pain a lot in my back and two sores on my butt. When asked if she could move herself around in her bed, the resident stated she did not attempt to reposition herself in bed because it hurts too much. The resident also stated that she had a sore on her right heel and it hurts like hell. I think it's because I'm just laying in bed. I can wiggle my toes but I can't move my foot off the pillows. It's damn scary to be worried about my foot . On 5/25/21 at 1:23 PM, a follow up interview was conducted with resident 108. Resident 108 stated that staff repositioned her in bed but they don't do it very often. I'll have to call for someone to help. The resident stated that she also had two painful sores on her bottom, that she was admitted with, but my butt feels like its on fire. It needs to be moved. On 5/24/21 a continuous observation was made of resident 108 as follows: a. At 11:35 AM, resident 108 was observed to be in her room in seated her bed, with the head of the bed elevated, and her legs outstretched toward the end of the bed. b. At 12:33 PM, a staff member entered the room to deliver resident 108's lunch tray. c. At 1:10 PM, the Social Services Worker (SSW) entered the room, seated herself in a chair, and spoke with resident 108 for several minutes. d. At 1:23 PM, a staff member entered resident 108's room and obtained a blood sugar sample. e. At 1:41 PM, a staff member entered resident 108's room and administered resident 108's insulin. f. At 2:22 PM, a staff member entered resident 108's room to assist resident 108 out of bed and into her wheelchair. During the duration of the observation from 11:35 AM to 2:22 PM, no staff members were observed to reposition resident 108, nor did resident 108 make any efforts to reposition her buttocks or her legs. On 5/28/21 at 12:55 PM, two staff members were observed to enter resident 108's room. They slid resident 108 up in bed, but did not reposition her right heel. The right heel was observed to be directly laying on a pillow, instead of being floated. 4. Resident 112 was admitted to the facility on [DATE] and 1/1/19 with diagnoses which included multiple sclerosis, benign prostatic hyperplasia with lower urinary tract symptoms, mononeuropathy, and dementia with behavioral disturbance. On 5/24/21 at 10:02 AM, an interview was conducted with resident 112. Resident 112 stated that he needed his brief to be changed. Resident 112 was observed to have a foul odor. Resident 112 stated that he wanted to have his brief changed every 2 hours, but not allowed to be changed until every 4 hours. Resident 112 stated that he has not been continent for most of his life. Resident 112 stated that he has a red buttocks and back from sitting in his urine for long periods of time. At 10:30 AM, a therapy staff member wheeled resident to the therapy gym. At 12:40 PM, resident 112 was observed outside the dining room in his wheelchair. Resident 112 stated he had not been changed. At 1:19 PM, an observation was made of resident 112 with CNA 12 and CNA 14 buttocks and backside. Resident 112 was observed to have red areas with small opening that were bleeding. On 5/24/21 at 1:25 PM, an interview was conducted with CNA 10. CNA 10 stated that resident 112 was compliant with brief changes. CNA 10 stated that resident 112 has set times to have his brief changed. CNA 10 stated usually after smoking he was changed. CNA 10 stated that his butt is terrible. CNA 10 stated that she slathers his buttocks with cream. CNA 10 stated that his buttocks is from sitting in a soiled brief for to long and not being changed. CNA 10 stated she thought the bleeding was from hemorrhoids. On 5/24/21 at 1:30 PM, an interview was conducted with CNA 12. CNA 12 stated that she changed resident 112's brief when he got up this morning. CNA 12 stated that therapy did not do brief changes. CNA 12 stated that resident 112 had sores and dead skin on his buttocks. CNA 12 stated that sometime his back side bleeds like it did today. CNA 12 stated that resident 112 should have been changed around his smoke break which was about 10:30 AM. CNA 12 stated that another CNA should have changed his brief before he left for therapy. CNA 12 stated resident 112 did not have a brief change until 1:30 PM. Resident 112's medical record was reviewed 5/24/21 through 5/28/21. A quarterly MDS dated [DATE] revealed resident 112 was frequently incontinent of bowel and bladder. Resident 112 had not been on a toileting program for bowel or bladder. Resident 112 had a BIMS of 11 which revealed mild cognitive impairment. A care plan dated 5/19/15 revealed, Has bowel incontinence r/t MS The goal developed were Will have less than two episodes of incontinence per day through the review date. The interventions developed were Check resident [with] rounds and prn and assist with toileting as needed and Provide pericare after each incontinent episode According to the CNA documentation in the tasks section from 4/29/21 until 5/28/21 resident 112 had 4 continent bowel episodes and 1 continent bladder episode. CNA documentation further revealed that resident 112 was documented as being toileted at 7:40 AM. Resident 112's Bowel and Bladder Evaluation dated 1/28/21 and 4/28/21 resident 112 was an unlikely candidate for bowel and bladder re-training. The evaluation dated 4/28/21 revealed that resident 112 was always incontinent of bowel and bladder which made resident an unlikely candidate for re-training. On 5/24/21 at 12:45 PM, an interview was conducted with CNA 10. CNA 10 stated resident 112 was usually changed every 2 hours. CNA 10 stated that resident 112 was able to verbalize to staff when he needed to have a brief changed. CNA 10 stated it can be difficult when staffing is low to change resident 112 because he required 2 person assist with a hoyer lift. On 5/24/21 at 2:00 PM, an interview was conducted with the DON. The DON stated resident 112 was a 2 person assist with brief changes. The DON stated that resident 112 should receive a brief change every 2 hours. On 5/27/21 at 3:43 PM, an interview was conducted with RN 3. RN 3 stated stated that resident 112 was continent but he was hard to transfer so he used briefs. RN 3 stated that resident 112 was alert and Oriented x 4 (person, place, time, and situation). RN 3 stated that resident 112 knew what he wants and where he was. RN 3 stated that resident 112 was able to tell when he had a brief change. RN 3 stated that she was no aware of any skin issues and nothing had been reported to her regarding his buttocks. RN 3 stated resident 112 was not on a bowel and bladder retraining program. On 5/28/21 at 10:52 AM, a follow up interview was conducted with the DON. The DON stated that resident 112 was alert and oriented for the most part and able to tell staff what he wanted and needed. The DON stated that he was compliant with cares as long as it was not during a smoking break. The DON stated that he talked to the Wound Nurse regarding resident 112's buttocks. The DON stated that resident 112 had MASD which was caused by sitting in his urine for to long. B. The following examples were cited at a potential for harm related to abuse allegations: 1. Resident 105 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypercapnia, heart failure, major depressive disorder, anxiety disorder, and functional quadriplegia. On 5/26/21 at 9:46 AM, an interview was conducted with resident 105. Resident 105 stated that there was a nurse who was giving me a bad time. When asked to elaborate, resident 105 stated that when RN 7 administered resident 105's heparin, she sometimes doesn't clean my arm with an alcohol wipe before she gives me a heparin shot and she injects it quickly instead of slowly so it makes me bleed all over the pillowcase, my nightgown, and my pillow. Its all soaked with blood. Resident 105 stated that she asked RN 7 why she insisted on doing it that way when resident 105 had asked her to do it differently. Resident 105 stated that RN 7 responded by saying when you go to school to be a nurse, you can tell me how to give a shot. Resident 105 stated that she felt she was being verbally and physically abused. Resident 105 stated that she reported the alleged abuse to the DON the same day, as well as the next day, but nothing happened. Resident 105 stated that the DON told her he would speak to RN 7 about it, but nothing changed and she was still the same. Resident 105 stated that RN 7 had made my life miserable. On 6/8/21 at 4:00 PM, an interview was conducted with RN 7. RN 7 stated that she had had an issue with resident 105. When asked to explain, RN 7 stated that the resident would try and tell me how to giver her shots. I told her don't tell me how to do my job. I went to school to be a nurse. Unless she has a nursing degree, she can't tell me how to do my job. I'm working under my license, not hers. RN 7 then stated that the DON had approached her and stated that resident 105 was alleging that RN 7 was abusive to her. On 5/28/21 at 8:26 AM, the DON was informed of the allegations of verbal abuse toward resident 105 by RN 7. The DON stated that he was not aware of the situation, even though both RN 7 and resident 105 stated that he had spoken with them about it, and would investigate and report immediately. A review of the State Agency database revealed that the facility did not investigate or report the incident until 6/8/21, approximately 12 days after the incident was reported to the facility by the state surveyor. 2. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with left femur fracture, muscle weakness, diabetes, major depressive disorder, and major depressive disorder. On 5/26/21 at 11:56 AM, an interview was conducted with resident 17. Resident 17 was asked if he felt staff had been abusive. Resident 17 stated the other night I was messy and CNA 8 cam into his room crying. Resident 17 stated that CNA 8 told him that she did not get any respect and she was burned out. Resident 17 stated that she was very upset. Resident 17 stated that she was rough and rolled him over and changed his brief really fast. Resident 17 stated that she did not fully cover him back up and she did not fully clean him. Resident 17 stated that he reported it to the CNA coordinator. Resident 17's medical record was reviewed 5/26/21 through 5/28/21. A quarterly MDS dated [DATE] revealed that resident 17 had a BIMS score of 14 which revealed he was cognitively intact. On 5/27/21 at 9:55 AM, an interview was conducted with the CNA coordinator. The CNA coordinator stated when a resident reported any concerns or abuse from a resident, then he talked with the staff member. The CNA coordinator stated he then educated the CNAs. The CNA coordinator stated that some of the CNAs were really little so they seam a little rougher but they were not rough. The CNA coordinator stated that CNA 8 was a solid aide and he had to put her on the 300 hall rather than the 500 hall. The CNA coordinator stated that he had not received any reports regarding resident 17 and CNA 8. On 5/28/21 at 1:07 PM, a phone interview was conducted with CNA 8. CNA 8 stated there were issues with staffing. CNA 8 stated a lot of time we were running with low staff. CNA 8 stated there have been times when we have had issues and I've had to run my tail off. CNA 8 stated there had been times that I have been on a hall with 30 residents and my partner goes on break and there are 20 call lights going. CNA 8 stated I have had moments when my stress level has gotten so high that I have just shut down. CNA 8 stated At work try to keep emotions in check but several times she remembered being really stressed. CNA 8 stated that resident 17 had noticed when something with me is off and will ask me what is wrong. CNA 8 stated that resident 17 had to wait for long periods of time to be changed out of a dirty brief because someone was on break. CNA 8 stated that the CNA coordinator call her in and told her not to tell residents when she was short staffed. CNA 8 stated that she had voiced she was burnt out to the CNA coordinator and then she was assigned on the 300 hall instead of the 500 hall where she liked to work. CNA 8 stated that the CNA coordinator did not listen to her concerns. On 5/28/21 at 7:57 AM, an interview was conducted with CRN 2. CRN 2 stated that the DON and Administrator completed the abuse investigations. On 5/28/21 at 10:52 AM, an interview was conducted with the DON. The DON stated he did not have an abuse investigation for resident 17. The DON stated that he was not aware that resident 17 had complained about care from a CNA. The DON was told that resident 17 had complained a CNA treated him abusively. A review of the FRI reports through the State Survey agency on 6/7/21 revealed there were no reported abuse investigations. 3. Resident 101 was admitted to the facility on [DATE] with diagnoses which included vascular dementia, essential tremor, hyperlipidemia, hypertension, anxiety disorder, major depressive disorder, chronic pain, chronic respiratory failure, tracheostomy status, functional quadriplegia, insomnia, multiple sclerosis, and spina bifida. On 5/28/21 at 1:17 PM, an interview was conducted with resident 101. When asked if he had ever felt like he was abused at the facility, resident 101 stated that on one occasion, RN 7 entered his room to provide cares, at which time resident 101 told RN 7 can you give me a minute? I'm on the phone with my girlfriend. Resident 101 stated that RN 7 responded by saying I'm here to do your cares now, your girlfriend can call you back. Resident 101 stated that RN 7 has said rude things before this incident, and that they don't treat me with the kind of respect I deserve. My bedroom is my domain. I live here. The nurses don't have the right to speak to anyone that way. Resident 101 stated that both RN 7 and LPN 4 have told him on multiple occasions that this isn't a hotel when resident 101 asked for assistance with something. Resident 101 stated that on those occasions he told the nurses that he realized he wasn't living in a hotel but its still my home. Resident 101 stated that he had reported his concerns to management with regard to how he was being treated, but they don't resolve it. I don't want to get people in trouble, I just want them educated and courteous. On 6/8/21 at 4:00 PM, an interview was conducted with RN 7. RN 7 stated that she has had conversations with resident 101 and his girlfriend regarding their phone calls. RN 7 stated that resident 101's girlfriend would call the facility and tell staff that resident 101 would like a pain pill, but when I get there he (resident 101) says to come back in five minutes. I've explained to her that she (resident 101's girlfriend) can call back in 5 minutes when we are done with his (resident 101's) care. Review of the facility grievance log revealed a grie[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 17 of 51 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute sepsis, a resident sustained a fall resulting in a head laceration due to a one person assist when two people were required, a resident with pressure ulcers (PU) was not repositioned for an observed 3 hour time period, a resident was not provided incontinence care resulting in moisture associated skin damage (MASD) with an open area and a bloody presentation. These findings were cited at a harm level for 4 resudents. In addition, a resident reported attempting to hold their bowel movements at night due to safety concerns with a one person assistance with incontinence care, and a resident reported being left unattended on a commode for 90 minutes. Additionally, multiple residents reported delayed incontinence care and being left for extended periods of time in soiled and wet briefs which resulted in skin irritation, typical call light response times of two hours, and residents reported needing assistance with eating and none was provided. Furthermore, multiple staff members reported staffing shortages that resulted in unsafe conditions for residents and the inability to complete the necessary cares, medication administration, and services for residents. Resident identifiers: 1, 8, 37, 56, 59, 61, 84, 85, 88, 94, 96, 98, 99, 101, 105, 108, 112. Findings include: A. The following examples were cited at a HARM level related to insufficient nursing staff: 1. Resident 84 was admitted to the facility 1/1/21. He has a history of traumatic subdural hemorrhage, nontraumatic subarachnoid hemorrhage, falls, tracheostomy, neuromuscular dysfunction of the bladder, chronic respiratory failure, quadriplegia, dependence on respirator, insomnia, Parkinson's disease and dementia. Resident 84's medical record was reviewed on 5/23/21. On 5/20/21 at 10:23 PM, a nursing progress note indicated that resident 84's Foley cath (catheter) is patent and draining well at this time. On 5/22/21 at 7:48 PM, a nursing progress note indicated that res (resident) continued with no urine output since cath change to collect UA (urinalysis) and diaphoresis. MD order received at 1850 (6:50 PM) to transport resident to [name of local emergency room]. [Name of local city paramedics] arrived at 1910 (7:10 PM) to transport and left at 1930 (7:30 PM). The nurses note did not indicate the date or time the catheter had been changed. On 5/22/21 the emergency room Report for resident 84 indicated that the facility staff note that they went to change the patients Foley catheter today for source control and had not had urine output since. They also note change in trach (tracheostomy) sputum upon suctioning from clear to green. emergency room Physician diagnoses included acute sepsis, pneumonia (ventilator associated), acute UTI (urinary tract infection). The emergency room Report also documented that a urinalysis indicated red colored urine, turbid in nature, nitrites present in abnormal nature, large amount of hemoglobin, proteins present at greater than 3000, Large abnormal [NAME] Blood Cells and bacteria 3 plus. On 5/22/21, a Computerized Tomography scan was performed in the Emergency Room. The impression from the radiologist included prominently distended bladder. The Foley catheter is malpositioned, the balloon is just inferior to the prostal gland. There is bilateral hydroureter with bilateral hydronephrosis, likely secondary to bladder outlet obstruction. On 5/25/21 at 10:06 AM, a record review showed a late entry progress note for 5/23/21 regarding resident 84. The nursing progress note stated that resident 84 was hospitalized on [DATE]. The note also stated that patient was reported to be tachy (tachycardic) with a HR (heart rate) reaching 145 and a low grade fever. Patient was assessed and on call was notified of the change at 1000 (10:00 AM). Orders were received to do CBC (complete blood count) and CRP (C-Reactive Protein). Due to patient being very dehydrated and all staff efforts being without good outcome, [primary physician]had to be contacted to get a PIV (peripheral intravenous) to draw from as well as have a line in place. [Primary physician] placed PIV at 1715 (5:15 PM) and sample was taken to the lab. No urine output had been seen since midmorning and RN (Registered Nurse) suspected it clogged and was told to change it to get culture. catheter was changed at 1500 (3:00 PM) and no urine was produced. RN notified on call. On call at 1845 (6:45 PM) called and told the night RN to send patient out. [Note: It should be noted that resident 84's physician orders indicated that resident 84 was exclusively hydrated and fed via a feeding tube, therefore it is unclear how resident 84 became dehydrated as indicated in the nurses progress note on 5/23/21.] On 5/23/21 a confidential staff interview was conducted with Staff Member (SM) 2. SM 2 stated that resident 84 should have been rounded on every two hours. SM 2 stated that the facility was so short staffed on multiple occasions that the staff wasn't able to check the fullness of residents' catheter bags. SM 2 stated that he/she frequently saw resident catheter bags filled to capacity, as well as residents' catheter bags not being emptied timely. SM 2 stated that on the day of hospitalization, resident 84's catheter was not flowing and the catheter bag was full. SM 2 stated the resident's physician was notified, and the catheter was changed to get clean urine for a urinalysis. SM 2 stated that the new catheter was not draining, and resident 84 then had a bladder scan with no reading. SM 2 then stated that resident 84's physician requested that resident 84 be sent to the local emergency room. SM 2 stated that he/she felt the resident was septic because no one changed resident 84's catheter bag in a timely manner. 2 . Resident 1 was admitted on [DATE] with diagnoses that included functional quadriplegia, diabetes mellitus, chronic respiratory failure with hypoxia, dysphagia, muscle weakness, , hypertension, difficulty walking, atrial fibrillation, and morbid obesity. Resident 1's medical record was reviewed on 5/23/21. Resident 1's quarterly Minimum Data Set (MDS) admission assessment dated [DATE] was reviewed. The MDS indicated that resident 1 required extensive assistance with 2 staff members for bed mobility, and was totally dependent on 2 staff members for transferring. Nurses notes for resident 1 revealed the following: a. On 5/12/21 at 8:00 PM, CNA found RN and alerted her that patient had fallen out of bed during a brief change and was on the floor. CNA states she was changing the resident when she ran out of wipes. She told the resident to go ahead and roll back while she went and got more wipes. The resident then rolled forward rolling off the bed and onto the floor instead of rolling backwards onto her back. CNA returned to the room to find the resident on the floor. Resident head was resting on the stand holding the ventilator and posterior head was actively bleeding . Res (Resident) c/o (complains of) pain all over body and especially her head. Res was assisted back into Bed and Posterior head was clean and area assessed. 1.5 inch laceration and goose bump noted to posterior head . NP (Nurse Practitioner) notified and gave orders to transport Res to [name of local emergency room] . b. On 5/13/21 at 1:20 AM, Resident was transferred back to facility via [name of ambulance company] 3 staples noted to laceration on posterior head. Res Noted to have bruised ribs. Staples to be removed 5/19/21. Resident 1's Medication Administration Record (MAR) indicated that resident 1 received a tramadol for pain on the following dates and times: a. On 5/13/21 at 12:46 PM for pain 10/10 b. On 5/14/21 at 7:57 AM for pain 2/10 c. On 5/14/21 at 7:48 PM for pain 5/10 [Note: Resident 1 did not receive any other tramadol during the month of May 2021 as of 5/26/21.] The MAR also indicated that resident 1 complained of pain 9/10 during the night shift on 5/12/21. Physical therapy notes dated 5/12/21 documented that resident 1 required maximum assistance for bed mobility training. Physical therapy notes dated 5/14/21 documented that resident 1 was still not feeling like herself after falling out of bed; body aches due to fall. Physical therapy notes dated 5/18/21 documented that resident 1 was extremely anxious and did not want to attempt sitting EOB (end of bed) today either; has taken a big step back since her fall a week ago. On 5/23/21 at 7:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that after the incident on 5/12/21 with resident 1, we took all agency staff off that hall. Now all staff that are up there are our people or are agency who have trained for that hall and know how to reposition those residents. The DON also stated that the CNA left the resident on her side when she left the room and that the CNA should not have left the resident on her side. She should have laid her (the resident) back down on her back and taken all of the supplies in with her. On 5/24/21 at 10:30 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 1 needs two people to change her. She's a total assist. CNA 3 further stated that when he changed resident 1's briefs, he always used two people because the bed is kind've small so I can pull her over to the side to give me enough space, so in case she falls forward she falls into the bed. On 5/24/21 at 10:55 AM, an interview was conducted with resident 1. Resident 1 stated that she was unable to move herself around in bed. When asked about the incident on 5/12/21, resident 1 stated that there were usually two people that changed her brief, but on 5/12/21 it was only one. Resident 1 stated that the lone staff member had rolled the resident to her right side on the edge of the bed and left the room. Resident 1 stated that she had subsequently fallen out of the bed and hit her head on the equipment next to her bed. Resident 1 stated that it was scary. On 5/23/21, a confidential staff interview was conducted with SM 2. SM 2 stated that the facility was poorly staffed. SM 2 stated that all the residents on the 500 hall should be 2 person assistance with brief changes. SM 2 stated that it's dangerous how low the staffing was for the 500 hall. SM 2 stated that there was one agency CNA for the 500 hall one day, and that resident 1 had an accident because there was only one CNA. SM 2 stated that resident 1 was rolled to her side for a brief change. SM 2 stated that the agency CNA left the room to get wipes and resident 1 rolled out of bed. SM 2 stated that when resident 1 rolled out of bed she hit her head and ended up with stitches. SM 2 stated when Agency CNAs worked on the 500 hall there were a lot more accidents. 3. Resident 108 was admitted to the facility on [DATE] with diagnoses that included pneumonia, muscle weakness, difficulty in walking, need for assistance with personal care, cognitive communication deficit, heart failure, dementia, urinary tract infection, hyperlipidemia, hypertension, diabetes, and chronic pain. Resident 108's medical record was reviewed on 5/23/21. On 4/29/21, staff completed an Initial admission Record for resident 108. The admission record indicated that resident 108 had a blister on left heel, old pressure wound on coccyx. There were no measurements or description of either wound. On 4/30/21, staff completed an Initial admission Record for resident 108. The admission record indicated that resident 108 had a blister on left heel, old pressure wound on coccyx. There were no measurements or description of either wound. On 4/30/21, staff completed a document entitled Functional Performance Evaluation. The evaluation indicated that resident 108 requiredsubstantial/maximal assistance with sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed to chair transfer. On 4/30/21, staff completed a document entitled Braden Scale for Predicting Pressure Sore Risk. The document indicated that resident 108 was slightly limited in her ability to respond to pressure-related discomfort, had skin that was occasionally moist, was chairfast, and was slightly limited in her ability to change and control body position. The document also indicated that resident 108 was at low risk for developing a pressure sore. On 4/30/21 staff developed a care plan for resident 108 that indicated resident had a self care performance deficit related to immobility and weakness. The care plan indicated that resident 108 required Extensive assistance 2 staff participation to reposition and turn in bed. On 5/3/21 staff completed a weekly skin evaluation. Staff indicated that there were no wounds, and no new skin issues. On 5/10/21 staff completed a weekly skin evaluation. Staff indicated that there were no wounds, and no new skin issues. Nurses notes for resident 108 indicated the following note: On 5/12/21 wound team note. team notified 5/11 of sores present on admit. [Resident 108] has MASD under L (left) breast, center to L [NAME] (sic), and BL (bilateral) buttock, scaring (sic) noted on BL buttocks from old wounds. she has a fluid filled blister on her R (right) heel, 4.7x4.5xUTD (unable to determine). PI (pressure injury) unstageable. dark in color. no drainage. no s/s (signs or symptoms) of infection. [NAME] (Decubitis ulcer) noted on the L pad of foot. old and very stable, 0.5x0.7xUTD. education on offloading. On 5/12/21 staff developed a care plan for resident 108 that stated Has pressure ulcer development to R (right) heel r/t (related to) immobility. The care plan also stated that the pressure ulcer was present on admission, was unstageable, and was 4.7 centimeters by 4.5 centimeters in size. On 5/12/21 staff also developed a care plan for resident 108 that stated resident 108 Has actual impairment to skin integrity r/t MASD. [Note: The initial skin integrity care plan for resident 108 developed on 4/30/21 did not indicate that resident 108 had any impairments to her skin integrity.] Resident 108's physician orders were reviewed. On 5/12/21, resident 108 had an order written for Wound care to L pad of foot: [NAME], and Wound care to R heel: PI unstageable. No orders for wound care were written prior to 5/12/21. On 5/18/21 staff completed a weekly skin evaluation. Staff documented that resident 108 had an unstageable pressure ulcer to her R heel that was present on admission. However, no notes could be located in resident 108's medical record to indicate that resident 108 had any skin issues on her R heel prior to 5/11/21. In addition, nurses notes did not indicate that the wound team was notified of any skin issues prior to 5/11/21. On 5/19/21 Wound Assessment Progress Note was completed by a wound specialist. The note indicated that resident 108 had an unstageable pressure ulcer on her right heel that was 4.7x4.5xUTD in size. The note also indicated the that wound was intact, dark discoloration [with] fluid and boggy. The note indicated that resident 108 had a skin issue on her left heel that was resolved. On 5/28/21 at 2:00 PM, an interview was conducted with the facility Wound Nurse (WN). The WN stated that resident 108's heel should not be placed directly on the bed or a pillow. The WN stated that resident 108 doesn't have a lot of mobility in her right leg. The WN stated that resident 108 would try to lift her R leg but doesn't succeed. The WN stated that resident 108 was admitted with a blister to her right heel. When asked why there was no documentation about a wound to her R heel prior to 5/11/21 or treatment implemented prior to 5/12/21, the WN stated he did not know. On 5/24/21 at 11:05 AM, an interview was conducted with resident 108. When asked about her stay, resident 108 stated I'm not getting very good care here. Resident 108 stated that she had pain a lot in my back and two sores on my butt. When asked if she could move herself around in her bed, the resident stated she did not attempt to reposition herself in bed because it hurts too much. The resident also stated that she had a sore on her right heel and it hurts like hell. I think it's because I'm just laying in bed. I can wiggle my toes but I can't move my foot off the pillows. It's damn scary to be worried about my foot . On 5/25/21 at 1:23 PM, a follow up interview was conducted with resident 108. Resident 108 stated that staff repositioned her in bed but they don't do it very often. I'll have to call for someone to help. The resident stated that she also had two painful sores on her bottom, that she was admitted with, but my butt feels like its on fire. It needs to be moved. On 5/24/21 a continuous observation was made of resident 108 as follows: a. At 11:35 AM, resident 108 was observed to be in her room in seated her bed, with the head of the bed elevated, and her legs outstretched toward the end of the bed. b. At 12:33 PM, a staff member entered the room to deliver resident 108's lunch tray. c. At 1:10 PM, the Social Services Worker (SSW) entered the room, seated herself in a chair, and spoke with resident 108 for several minutes. d. At 1:23 PM, a staff member entered resident 108's room and obtained a blood sugar sample. e. At 1:41 PM, a staff member entered resident 108's room and administered resident 108's insulin. f. At 2:22 PM, a staff member entered resident 108's room to assist resident 108 out of bed and into her wheelchair. During the duration of the observation from 11:35 AM to 2:22 PM, no staff members were observed to reposition resident 108, nor did resident 108 make any efforts to reposition her buttocks or her legs. On 5/28/21 at 12:55 PM, two staff members were observed to enter resident 108's room. They slid resident 108 up in bed, but did not reposition her right heel. The right heel was observed to be directly laying on a pillow, instead of being floated. 4. Resident 112 was admitted to the facility on [DATE] and 1/1/19 with diagnoses which included multiple sclerosis, benign prostatic hyperplasia with lower urinary tract symptoms, mononeuropathy, and dementia with behavioral disturbance. On 5/24/21 at 10:02 AM, an interview was conducted with resident 112. Resident 112 stated that he needed his brief to be changed. Resident 112 was observed to have a foul odor. Resident 112 stated that he wanted to have his brief changed every 2 hours, but not allowed to be changed until every 4 hours. Resident 112 stated that he has not been continent for most of his life. Resident 112 stated that he has a red buttocks and back from sitting in his urine for long periods of time. At 10:30 AM, a therapy staff member wheeled resident to the therapy gym. At 12:40 PM, resident 112 was observed outside the dining room in his wheelchair. Resident 112 stated he had not been changed. At 1:19 PM, an observation was made of resident 112 with CNA 12 and CNA 14 buttocks and backside. Resident 112 was observed to have red areas with small opening that were bleeding. On 5/24/21 at 1:25 PM, an interview was conducted with CNA 10. CNA 10 stated that resident 112 was compliant with brief changes. CNA 10 stated that resident 112 has set times to have his brief changed. CNA 10 stated usually after smoking he was changed. CNA 10 stated that his butt is terrible. CNA 10 stated that she slathers his buttocks with cream. CNA 10 stated that his buttocks is from sitting in a soiled brief for to long and not being changed. CNA 10 stated she thought the bleeding was from hemorrhoids. On 5/24/21 at 1:30 PM, an interview was conducted with CNA 12. CNA 12 stated that she changed resident 112's brief when he got up this morning. CNA 12 stated that therapy did not do brief changes. CNA 12 stated that resident 112 had sores and dead skin on his buttocks. CNA 12 stated that sometime his back side bleeds like it did today. CNA 12 stated that resident 112 should have been changed around his smoke break which was about 10:30 AM. CNA 12 stated that another CNA should have changed his brief before he left for therapy. CNA 12 stated resident 112 did not have a brief change until 1:30 PM. Resident 112's medical record was reviewed 5/24/21 through 5/28/21. A quarterly MDS dated [DATE] revealed resident 112 was frequently incontinent of bowel and bladder. Resident 112 had not been on a toileting program for bowel or bladder. Resident 112 had a BIMS of 11 which revealed mild cognitive impairment. A care plan dated 5/19/15 revealed, Has bowel incontinence r/t MS The goal developed were Will have less than two episodes of incontinence per day through the review date. The interventions developed were Check resident [with] rounds and prn and assist with toileting as needed and Provide pericare after each incontinent episode According to the CNA documentation in the tasks section from 4/29/21 until 5/28/21 resident 112 had 4 continent bowel episodes and 1 continent bladder episode. CNA documentation further revealed that resident 112 was documented as being toileted at 7:40 AM. Resident 112's Bowel and Bladder Evaluation dated 1/28/21 and 4/28/21 resident 112 was an unlikely candidate for bowel and bladder re-training. The evaluation dated 4/28/21 revealed that resident 112 was always incontinent of bowel and bladder which made resident an unlikely candidate for re-training. On 5/24/21 at 12:45 PM, an interview was conducted with CNA 10. CNA 10 stated resident 112 was usually changed every 2 hours. CNA 10 stated that resident 112 was able to verbalize to staff when he needed to have a brief changed. CNA 10 stated it can be difficult when staffing is low to change resident 112 because he required 2 person assist with a hoyer lift. On 5/24/21 at 2:00 PM, an interview was conducted with the DON. The DON stated resident 112 was a 2 person assist with brief changes. The DON stated that resident 112 should receive a brief change every 2 hours. On 5/27/21 at 3:43 PM, an interview was conducted with RN 3. RN 3 stated stated that resident 112 was continent but he was hard to transfer so he used briefs. RN 3 stated that resident 112 was alert and Oriented x 4 (person, place, time, and situation). RN 3 stated that resident 112 knew what he wants and where he was. RN 3 stated that resident 112 was able to tell when he had a brief change. RN 3 stated that she was no aware of any skin issues and nothing had been reported to her regarding his buttocks. RN 3 stated resident 112 was not on a bowel and bladder retraining program. On 5/28/21 at 10:52 AM, a follow up interview was conducted with the DON. The DON stated that resident 112 was alert and oriented for the most part and able to tell staff what he wanted and needed. The DON stated that he was compliant with cares as long as it was not during a smoking break. The DON stated that he talked to the Wound Nurse regarding resident 112's buttocks. The DON stated that resident 112 had MASD which was caused by sitting in his urine for to long. 5. Resident 99 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis, post-traumatic stress disorder, muscle weakness, anxiety disorder and major depressive disorder. On 5/26/21 at 11:22 AM, an interview was conducted with resident 99. Resident 99 stated that she attempted suicide after an agency Certified Nursing Assistant (CNA) treated her terrible. Resident 99 stated there were not enough staff and she felt like a burden on staff. Resident 99 stated that she tried to cut my throat. Resident 99 stated that she used a knife and put a hole in my neck. Resident 99 stated she was supposed to see a counselor after she returned from the hospital. Resident 99 stated that a counselor came into her room and said he was in a hurry and would come back to talk. Resident 99 stated she wanted to talk to a counselor but the counselor had not returned. Resident 99 stated that she had attempted suicide prior to admission as well. Resident 99's medical record was reviewed 5/26/21 through 5/28/21. A care plan dated 5/11/21 revealed, Resident has a history of suicide attempts. A goal developed was Resident will have no incidents of self harm. Interventions were Administer medications as ordered. Monitor/document for side effects and effectiveness, encourage to express feelings, Monitor/record/report to MD prn (as needed) risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med (medications) or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness, provide [local] Mental Health crisis number, resident followed by [local] Mental health. The Emergency Department History and Physical Report dated 3/19/21 at 3:41 PM revealed that resident 99 was .brought in by EMS (Emergency Medical Services), VS (vital signs) normal but pt (patient) unresponsive. Superficial self inflicted abrasion on right arm and chest/neck. The report further revealed, According to caregivers at the facility patient was in her normal state this morning. Her normal state is bedbound only moves right upper extremity and is conversant. Patient had mentioned to some of the workers that she wanted to kill herself. She had a visitor at the facility today. This afternoon patient was found unresponsive with superficial cut marks to her neck. Resident 99's progress notes revealed the entries: a. On 3/19/21 at 1:00 PM, At 1205 (12:05 PM) Aid reported that she went to check in on resident and noticed that resident had a pocket knife in her left hand and noticed that she had a cut on her lower R (right) forearm and bloody smear just below the front side of her neck. She immediately called out to the nurse who was outside the door and while nurse was with the resident she alerted another nurse for help. Upon arriving in residents room, writer noted that the first nurse was holding on to left hand to prevent resident from cutting herself and talking calmly to her. Resident was not combative and was not attempting to attack the staff. She appeared withdrawn, somewhat lethargic but was still coherent to answer appropriately. Staff was able to talk resident into letting the pocket knife go. Resident refused to answer specifically why she was upset. She said repeatedly 'I just want to die', 'I want to be with [name removed]', '[name removed] wants me to be with him', 'Put me in the ground next to [name removed]'. Resident was placed on one on one watch with staff. Provider, DON (Director of Nursing) and Administrator alerted to situation. Provider ordered to send resident to [local hospital] ED (Emergency Department) for further psychiatric and medical eval (evaluation) and treatment for suicidal ideation and action. Family notified of concerns. One of the daughters mentioned that resident has had suicidal ideation and attempts in the past at home and the reason why she was placed in a care center. Resident picked up by [local non-emergent ambulance company] [at] 1250 (12:50 PM) and transported to hospital via stretcher. b. On 3/22/21 at 3:42 PM, MD (Medical Doctor) recommended psych (psychological) evaluation, [local mental health company] notified and coordinating a visit for evaluation. c. On 3/26/21 at 9:43 AM, Late Entry: SW (Social Worker) spoke to [resident 99] about her SI (suicidal ideation) hospitalization and how she was feeling. [Resident 99] stated that she felt better and explained her attempt and what brought her to the ED. SW asked if she had met with the therapist and APRN (Advanced Practice Registered Nurse) that week and she said yes. SW asked if she had any SI ideation that week since returning and she said no. [Resident 99] spoke candidly with SW about her attempts.SW feels she is stable at this time. SW talk to nursing about possible plastic utensils. An Investigation regarding resident 99 suicide attempt was provided to the State Survey Agency. The undated form revealed that on 3/19/21 resident 99 had a suicide attempt. The follow up information revealed, .Resident requested a psychiatric visit to evaluate her mental state. [Local mental Health Company] Mental Health was coordinated to perform visit. Provider did write a new medication order to assist with her psychosocial well-being. House provider was updated on recommendation and order from psychiatric provider to which it was agreed to follow those recommendations. On 5/28/21 at 9:18 AM, a list was provided by the facility Discharge Planner. The list was resident names that the local mental health company was providing services to. Resident 99 was not on the list. The facility Discharge Planner responded that resident 99 was not receiving services but paperwork was being sent today to have resident 99 be on services the following week. On 5/27/21 at 12:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that there was no incident report for resident 99's suicide attempt. On 5/27/21 at 12:26 PM, an interview was conducted with CNA 12. CNA 12 stated that she was not working when resident 99 tried to hurt herself. CNA 12 stated that she worked the following day. CNA 12 stated that resident 99 told her that an agency CNA had told her she was a burden, like her husband always did. CNA 12 stated that resident 99 told her she had a knife or something sharp she pressed into her neck. CNA 12 stated that resident 99 told her that a nurse came in and found her. CNA 12 stated that resident 99 told CNA 12 that she was in the wrong head space. CNA 12 stated that resident 99's routine in the morning was usually an hour long and agency CNAs have been upset her routine was so long and told her she was a burden. On 5/27/21 at 2:00 PM, an interview was conducted with SSW 1. SSW 1 stated she started at the facility February 2021. SSW 1 stated resident 99 had a suicide attempt. SSW 1 stated she spoke with resident 99 after her suicide attempt. SSW 1 stated that resident 99 stated that she grabbed her knife from home after an agency CNA that was working with her was not very kind with her. SSW 1 stated that resident 99 told her she tried to stab herself with the knife. SSW 1 stated resident 99 was sent to hospital and was there for a bit and then came back. SSW 1 stated that when resident 99 returned to the facility a mental health company was contacted to work with resident 99. SSW 1 stated that resident 99 was seeing the mental health specialist weekly. SSW 1 stated she was not involved in care planning. SSW 1 stated she talked to management and the CNA coordi[TRUNCATED]

Based on observation, record review and interview the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, deficient practices were identified during the survey regarding abuse, neglect, falls, incontinence cares, pain, treatment for psychosocial concerns, and staffing. There were multiple residents who were identified to have outcomes cited at a harm level. Resident identifiers: 1, 8, 17, 37, 56, 61, 82, 84, 85, 88, 94, 96, 98, 99, 101, 102, 103, 105, 108, and 112. Findings include: 1. The facility administration did not ensure that for 7 out of 51 residents, the residents were free from abuse and neglect. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute sepsis, a resident sustained a fall resulting in a head laceration due to a one person assist when two people were required, a resident with pressure ulcers (PU) located on the bilateral heels did not have the heels floated as ordered and repositioning did not occur for an observed 3 hour time period, and a resident was not provided incontinence care resulting in moisture associated skin damage (MASD) with an open area and a bloody presentation. These examples of neglect were cited at a harm level. Additionally, a resident reported an allegation of verbal and physical abuse from a licensed nurse with medication administration, a resident reported an allegation of physical abuse from a Certified Nurse Assistant (CNA) during incontinence care, and a resident reported an allegation of rough treatment during incontinence care in September 2020 followed by an allegation of verbal abuse with cares by the same nurse in May 2021. Resident identifiers: 1, 17, 84, 101, 105, 108 and 112. [Cross refer to F600] 2. The facility administration did not ensure that for 1 of 51 sample residents, that the facility provided care to prevent unavoidable pressure ulcers, nor did they provide timely treatment and services for the resident's pressure ulcer. Specifically, a resident developed an unstageable pressure sore and was not provided interventions to prevent the pressure sore. In addition, after the pressure sore was developed treatment and services were not provided in a timely manner to heal the pressure sore. This resulted in a finding of harm. Resident identifier: 108. [Cross refer to F686] 3. The facility administration did not ensure that for 3 of 51 sample residents, residents did not receive adequate supervision and assistance devices to prevent accidents. Specifically, one resident was assisted with a brief change with only one staff member instead of two, resulting in the resident falling out of bed and sustaining a head laceration. This incident was found to have occurred at a harm level. In addition, a resident sustained a burn after a staff member placed a wet wash cloth from the microwave on the resident. This incident was found to have occurred at a harm level. Another resident was not assessed to determine if he was safe to smoke independently. Resident identifiers: 1, 37, and 103. [Cross refer to F689] 4. The facility administration did not ensure that for 6 of 51 sample residents, that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, the facility failed to ensure proper care for a resident with a urinary catheter which resulted in the resident being hospitalized . This finding was cited at a harm level. In addition, a resident was not toileted timely, resulting in the resident having skin breakdown. This finding was also cited at a harm level. In addition, residents were not placed on a bowel and bladder training program despite requests and staff assessment of appropriateness Resident identifiers: 37, 82, 84, 99, 102, and 112. [Cross refer to F690] 5. The facility administration did not ensure that for 16 of 51 sampled residents, the facility had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute sepsis, a resident sustained a fall resulting in a head laceration due to a one person assist when two people were required, a resident with pressure ulcers (PU) was not repositioned for an observed 3 hour time period, a resident was not provided incontinence care resulting in moisture associated skin damage (MASD) with an open area and a bloody presentation. These findings were cited at a harm level for 4 residents. In addition, a resident reported attempting to hold their bowel movements at night due to safety concerns with a one person assistance with incontinence care, and a resident reported being left unattended on a commode for 90 minutes. Additionally, multiple residents reported delayed incontinence care and being left for extended periods of time in soiled and wet briefs which resulted in skin irritation, typical call light response times of two hours, and residents reported needing assistance with eating and none was provided. Furthermore, multiple staff members reported staffing shortages that resulted in unsafe conditions for residents and the inability to complete the necessary cares, medication administration, and services for residents. Resident identifiers: 1, 8, 37, 56, 61, 84, 85, 88, 94, 96, 98, 99, 101, 105, 108, 112. [Cross refer to F725] 6. The facility administration did not ensure for 1 of 51 sample residents, that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practical mental and psychosocial well-being. Specifically, a resident that attempted suicide was not provided mental health services. This was found to have occurred at a harm level. Resident identifier: 99. [Cross refer to F742] On 5/24/21 at 3:44 PM, an interview was conducted with the facility Administrator (Admin). The Admin stated that there was a formal QA for staffing that started on 5/12/21 after resident 1 fell and sustained a laceration. The Admin stated that as of 5/24/21 he felt that the facility was fully staffed, but the staff were newer and would need to receive additional training. The Admin stated that the facility had been short staffed for a long time and that staff were still frustrated even though the facility was now fully staffed.

Based on observation, record review and interview the facility Quality Assessment and Assurance (QAA) Committee did not develop and implement appropriate plans of action to correct identified quality deficiencies. Specifically, deficient practices were identified during the survey regarding abuse, neglect, falls, incontinence cares, pain, treatment for psychosocial concerns, and staffing. There were multiple residents who were identified to have outcomes cited at a harm level. Resident identifiers: 1, 8, 17, 37, 56, 61, 82, 84, 85, 88, 94, 96, 98, 99, 101, 102, 103, 105, 108, and 112. Findings include: 1. The facility QAA Committee did not ensure that for 7 out of 51 residents, the residents were free from abuse and neglect. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute sepsis, a resident sustained a fall resulting in a head laceration due to a one person assist when two people were required, a resident with pressure ulcers (PU) located on the bilateral heels did not have the heels floated as ordered and repositioning did not occur for an observed 3 hour time period, and a resident was not provided incontinence care resulting in moisture associated skin damage (MASD) with an open area and a bloody presentation. These examples of neglect were cited at a harm level. Additionally, a resident reported an allegation of verbal and physical abuse from a licensed nurse with medication administration, a resident reported an allegation of physical abuse from a Certified Nurse Assistant (CNA) during incontinence care, and a resident reported an allegation of rough treatment during incontinence care in September 2020 followed by an allegation of verbal abuse with cares by the same nurse in May 2021. Resident identifiers: 1, 17, 84, 101, 105, 108 and 112. [Cross refer to F600] 2. The facility QAA Committee did not ensure that for 1 of 51 sample residents, that the facility provided care to prevent unavoidable pressure ulcers, nor did they provide timely treatment and services for the resident's pressure ulcer. Specifically, a resident developed an unstageable pressure sore and was not provided interventions to prevent the pressure sore. In addition, after the pressure sore was developed treatment and services were not provided in a timely manner to heal the pressure sore. This resulted in a finding of harm. Resident identifier: 108. [Cross refer to F686] 3. The facility QAA Committee did not ensure that for 3 of 51 sample residents, residents did not receive adequate supervision and assistance devices to prevent accidents. Specifically, one resident was assisted with a brief change with only one staff member instead of two, resulting in the resident falling out of bed and sustaining a head laceration. This incident was found to have occurred at a harm level. In addition, a resident sustained a burn after a staff member placed a wet wash cloth from the microwave on the resident. This incident was found to have occurred at a harm level. Another resident was not assessed to determine if he was safe to smoke independently. Resident identifiers: 1, 37, and 103. [Cross refer to F689] 4. The facility QAA Committee did not ensure that for 6 of 51 sample residents, that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, the facility failed to ensure proper care for a resident with a urinary catheter which resulted in the resident being hospitalized . This finding was cited at a harm level. In addition, a resident was not toileted timely, resulting in the resident having skin breakdown. This finding was also cited at a harm level. In addition, residents were not placed on a bowel and bladder training program despite requests and staff assessment of appropriateness Resident identifiers: 37, 82, 84, 99, 102, and 112. [Cross refer to F690] 5. The facility QAA Committee did not ensure that for 16 of 51 sampled residents, the facility had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute sepsis, a resident sustained a fall resulting in a head laceration due to a one person assist when two people were required, a resident with pressure ulcers (PU) was not repositioned for an observed 3 hour time period, a resident was not provided incontinence care resulting in moisture associated skin damage (MASD) with an open area and a bloody presentation. These findings were cited at a harm level for 4 residents. In addition, a resident reported attempting to hold their bowel movements at night due to safety concerns with a one person assistance with incontinence care, and a resident reported being left unattended on a commode for 90 minutes. Additionally, multiple residents reported delayed incontinence care and being left for extended periods of time in soiled and wet briefs which resulted in skin irritation, typical call light response times of two hours, and residents reported needing assistance with eating and none was provided. Furthermore, multiple staff members reported staffing shortages that resulted in unsafe conditions for residents and the inability to complete the necessary cares, medication administration, and services for residents. Resident identifiers: 1, 8, 37, 56, 61, 84, 85, 88, 94, 96, 98, 99, 101, 105, 108, 112. [Cross refer to F725] 6. The facility QAA Committee did not ensure for 1 of 51 sample residents, that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practical mental and psychosocial well-being. Specifically, a resident that attempted suicide was not provided mental health services. This was found to have occurred at a harm level. Resident identifier: 99. [Cross refer to F742] On 5/24/21 at 3:44 PM, an interview was conducted with the facility Administrator (Admin). The Admin stated that there was a formal QA for staffing that started on 5/12/21 after resident 1 fell and sustained a laceration. The Admin stated that as of 5/24/21 he felt that the facility was fully staffed, but the staff were newer and would need to receive additional training. The Admin stated that the facility had been short staffed for a long time and that staff were still frustrated even though the facility was now fully staffed. On 5/24/21 at approximately 12:00 PM, it was observed that as the Director of Nursing (DON) was obtaining average call light times, that there were no call light times recorded for the 100 hall (Memory Care Unit). When asked, he stated that the system did not record the 100 hall's call light times. Therefore, the QA program was not capturing an accurate picture of call light times in order to take to the QA committee.